York Hospital

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 46424 Based on document reviews and interviews, the hospital failed to ensure that Emergency Department policies were reviewed and updated for nine (9) of eighteen (18) policies reviewed. Findings: On 8/13/2025 at 11:00 AM, 18 Emergency Department policies were reviewed. Nine (9) policies have not been reviewed by the next review date listed at the top of each policy: - Triage Guidelines in the York Emergency Department (last revised 11/2018, next review 3/2025) - Administration of Intramuscular (IM) Methotrexate for the Treatment of Ectopic Pregnancy (last revised 1/2023, next review 3/2025) - Dispensing of Medication: Emergency Department (last revised 4/2021, next review 3/2025) - ED Care of the Patient with Suicidal/Homicidal Ideation (last revised 5/2018, next review 3/2025) - Helicopter Transfer from York Hospital (last revised 7/2019, next review 3/2025) - Legal Claim of Evidence for Emergency Department (last revised 1/2020, next review 3/2025) - Management of Acute Ischemic Stroke (last revised 10/2022, next review 3/2025) - On Call Physicians for EMTALA (last revised 9/2022, next review 3/2025) - Review of Lab/Radiology Reports (last revised 1/2020, next review 3/2025) On 8/13/2025 at 11:20 AM, the Chief Nursing Officer confirmed that there is no official policy on policy review, but that policies should be reviewed “every 3 years.” At 1:05 PM, the Chief Nursing Officer confirmed that these eight (8) policies are past their review dates. 49750 Based on document reviews and interviews, the hospital failed to ensure that Emergency Department patient records included documentation of: 1. A physical exam for one (1) of ten (10) medical records reviewed. (ED #8) 2. A mental status for seven (7) of ten (10) medical records reviewed. (ED #1, ED #2, ED #3, ED #5, ED #6;,ED #8, and ED #9) Findings: 1. On 8/13/2025, ED Pt. #8’s medical record was reviewed with the Compliance Officer. The review revealed that a physical exam was not documented in the medical record. The Compliance Officer confirmed this finding at that time. 2. On 8/13/2025, the medical records of ED #1, ED #2, ED #3, ED #5, ED #6, ED #8, and ED #9 were reviewed. The review revealed that a mental status exam was not documented in these medical records. The Compliance Officer confirmed these findings at that time.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital’s Governing Body failed to ensure: 1. The Medical Staff are appointed and reappointed in accordance with the Medical Staff and Hospital bylaws. 2. That patient care was provided by a Doctor determined to have concerns related to practicing medicine while impaired. 3. That the Medical Staff Office conducted periodic appraisals and evaluated peer review data. Findings: Failure to approve medical staff bylaws and other medical staff rules and regulations. The Governing Body failed to ensure that the Medical Staff Office followed the Medical Staff bylaws for the required approval signatures contained in nine (9) of nine (9) reviewed credential files. (Refer to A-0048 for details). Failure to ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. The Governing Body failed to ensure that the Medical Staff have an accountable and reliable processes to initiate the process and investigate, analyze, and address concerns regarding an impaired Doctor. This failure allowed the Human Resources Department and the Chief Executive Officer to allow this Doctor to work thirty-three (33) shifts and possibly have affected patient care, without review from the required Ad Hoc/Provider Health Committee. (Refer to A-0049 for details). Failure to ensure the criteria for selection are individual character, competence, training, experience, and judgment. The Governing Body failed to ensure that the Medical Staff’s credentialing file contained the following: Peer review and periodic appraisals for application approval for nine (9) of nine (9) files reviewed. (Refer to A-0050 for details). The cumulative effect of this deficient practice resulted in noncompliance with this Condition of Participation.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 42601 Based on document review and interviews, the Condition of Participation for Quality Assessment and Performance Improvement (“QAPI”) was not met as evidenced by the hospital’s failure to ensure that its QAPI Program reflected the hospital’s patient population, identified opportunities for improvement based on the collection of data and to identify any Performance Improvement projects for 2024, based on high-risk or problem-prone areas that affect health outcomes and patient care. There was no evidence that they considered the incidence, prevalence, and severity of problems in those areas and that the Governing Body failed to ensure that the QAPI Program reflects the complexity of the hospital’s organization and services. The hospital failed to ensure that it incorporated quality indicator data into the hospital’s QAPI Program. (See A-0273 for details) The hospital failed to ensure that Quality Program activities were based on high-risk, high-volume, or problem-prone areas that affect health outcomes and patient care. There was no evidence that they considered the incidence, prevalence, and severity of problems in those areas. (See A-0283 for details) The hospital failed to identify any Performance Improvement projects that had been identified in 2024. (See A-0297 for details) The hospital’s Governing Body failed to ensure that the QAPI Program reflects the complexity of the hospital’s organization and services and involves all hospital department and services (including those services furnished under contract or arrangement). (See A-0308 for details) There was no documented evidence that the Governing Body had taken full responsibility for the hospital-wide QAPI Program. (See A-0309 for details) The cumulative effect of this deficient practice resulted in noncompliance with this Condition of Participation.”

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure that the Medical Staff was brought to the credentialing committee with the required approval signatures, that the credential files contained any quality information and that a Doctor, who confirmed they were impaired and unable to care for patients, continued to work in the hospital. Findings: The hospital failed to ensure that each medical staff’s credentialing file contained the required signatures for application approval for nine (9) of nine (9) files reviewed (Doctor #1, #6, #9, #17 - #20, Nurse Practitioner (“NP”) #1 and #2). See A-0339 for details. The hospital failed to ensure that each medical staff’s credentialing file contained the following: Peer review and periodic appraisals for application approval for nine (9) of nine (9) files reviewed (Doctor #1, #6, #9, #17 - #20, Nurse Practitioner (“NP”) #1 and #2). See A-0340 for details. The Medical Staff Office failed to have an accountable and reliable processes to initiate the process and investigate, analyze, and address concerns regarding an impaired Doctor (Doctor #9). This failure caused the Human Resources Department to make decisions, that could have affected patient care, without the review of the Medical Executive Committee or Governing Body. See A-0347 for details. The cumulative effect of this deficient practice resulted in noncompliance with this Condition of Participation.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 48232 Based on document reviews, observations, and interviews, the hospital failed to meet the Condition of Participation Physical Environment as evidenced by the following: The hospital failed to ensure air distribution systems for the Operating Room suites received preventive maintenance to include but not limited to testing, adjusting, & balancing for over seven (7) years (A-0701). The hospital failed to ensure preventive maintenance and repairs were scheduled and performed in one (1) of two (2) Computed Tomography areas observed (A-0701). The hospital failed to ensure preventative maintenance and plumbing fixtures in the kitchen of the Medical/Surgical unit were repaired and maintained sanitary in one (1) of two (2) observed Medical/Surgical unit kitchens (A-0701). The hospital failed to ensure expired supplies were removed from circulation in York Hospital Emergency Care in Wells, and the Sterile Processing Department (A-0724). The hospital failed to ensure humidity levels were monitored and recorded in Operating Room #3 for the entire months of February, March, April, August, September, October, and November of 2024, and part of the months of May, July, and December of 2024 (A-0726). Please see A-0701, A-0724, & A-0726 for details.”

“MEDICAL STAFF - BYLAWS AND RULES CFR(s): 482.12(a)(4) [The governing body must] approve medical staff bylaws and other medical staff rules and regulations. This Standard is not met as evidenced by: 42601 Based upon document reviews and interviews, the Governing Body failed to ensure that the Medical Staff Office followed the Medical Staff bylaws for the required approval signatures contained in nine (9) of nine (9) reviewed credential files. Findings: The “York Hospital Medical Staff Bylaws and Regulations”, last revised in 05/2019 states, in part, “All those eligible under these Bylaws, who have delineated clinical privileges, and who seek to have patient care responsibilities, must make application for appointment and reappointment to either the Medical Staff. Appointments and reappointments are the legal right and responsibility of the Board of Trustees of the Hospital and will be based on the findings and recommendations of the Bylaws & Credentials Committee and the Medical Executive Committee (MEC). ... The completed application, with supporting documents, shall be forwarded to the Medical Staff Office. After the application has been processed and verifications completed, the Department Chief of the Department in which the applicant seeks clinical privileges will review the application to determine if he or she meets the criteria of education, training, and experience for membership and the clinical privileges requested and make his or her recommendation. The application and all supporting material shall then be sent to the Bylaws and Credential Committee for evaluation and recommendation.” In addition, “The Board shall consider the recommendations for reappointment or non-reappointment and shall direct Administration to notify the applicant, and if reappointed, shall secure his or her signed agreement to be governed by these Bylaws, Rules & Regulations, and Policies & Procedures. In the case of non-reappointment or change in clinical privileges, the Staff member has the right to exercise or waive his or her right to Fair Hearing as provided in the Bylaws of York Hospital. The Board shall not take action (denial, or reduction in privileges) in opposition to MEC recommendation on any reappointment without a prior Joint Conference with the MEC.” On 01/09/2025 at 1:06 PM, nine (9) Medical Staff were chosen and their credentialing files were reviewed with the Medical Staffing Office Coordinator. - There was no documented evidence of signed Requested Privileges form by Department Chief, Bylaws and Credentials Committee, Medical Executive Committee or Board of Trustees for the reviewed Medical Staff. The Medical Staffing Office Coordinator stated the following: - There has been brainstorming. It was in the plan of correction that I was to obtain the signatures; - I wasn’t a part of writing the plan of corrections but was told about it; - We started going back to the beginning to the older files that had not been signed; - COVID changed everything and it sounds bad but I got out of the habit [of getting the required signatures] and haven’t gotten back into that; - It is very important that signatures were completed and that is a function of my role; - I can’t offer an explanation; and - I did not bring the files for them to sign. On 01/09/2025 at approximately 3:00 PM, an interview was conducted with the Director of Compliance and Privacy in regard to the missing signatures. He stated the following: - I started the audit; and - I stopped everything because I realized how badly broken the operation was.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the Governing Body failed to ensure that the Medical Staff have an accountable and reliable processes to initiate the process and investigate, analyze, and address concerns regarding an impaired Doctor (Doctor #9). This failure allowed the Human Resources Department and the Chief Executive Officer to allow Doctor #9 to work thirty three (33) shifts and possibly have affected patient care, without the review from the required Ad Hoc/Provider Health Committee. Findings: The “York Hospital Medical Staff Bylaws and Regulations”, last revised in 05/2019 states, in part, “A. The provision of quality patient care is of primary importance to York Hospital, its Board of Trustees and its Medical Staff. It is recognized that practitioners who are suffering from physical or mental impairments may compromise the quality of patient care. York Hospital has developed this procedure to help identify, monitor and address practitioners with impairments. It is the policy of York Hospital to encourage disclosure by practitioners of any impairment which might affect the ability to safely practice medicine, to assist such practitioners in obtaining necessary treatment and, when appropriate, to provide reasonable accommodations to allow such practitioners to continue the practice of medicine. B. Impaired practitioner is any practitioner suffering from a physical or mental illness, excessive use or abuse of drugs or alcohol, or deterioration due to the aging process which might impair his or her ability to practice medicine with a reasonable degree of skill and safety. Ad Hoc/Provider Health Committee: C. Appointment: There shall be a minimum of three (3) but no more than five (5) providers on an Ad Hoc/Provider Health Committee, appointed as necessary by the Chair of the Medical Executive Committee when there are reasonable grounds for review. The Medical Executive Committee will determine if there is a reasonable ground to convene. D. Reasonability: The Provider Health Committee shall assist the Medical Executive Committee in the monitoring of the clinical performance of individuals with delineated clinical privileges. The Committee shall act as a resource for any Impaired Practitioner and may recommend treatment, counseling, etc. If any information is brought to the attention of the Provider Health Committee indicating that a practitioner is or may be impaired, the Committee or a member thereof may interview the provider and offer or recommend treatment, further evaluation or modification/restrictions to the practitioner’s practice. The practitioner may also be referred to the Provider Health Program of the Maine Medical Association. The Provider Health Committee shall have no authority to impose any discipline or mandate any action involving the Provider. However, if the practitioner does not accept the Committee’s assistance or recommendations the Committee shall report their findings and recommendations to the President of the Medical Staff. E. Reports to the Provider Health Committee: All members of the Medical Staff and employees of York Hospital are encouraged to consult with the Medical Staff President and/or the Hospital President if there are reasonable grounds to suspect that another member of the Medical Staff is impaired. Members of the Medical Staff are also encouraged to disclose to the Committee, or a member thereof, their own physical or mental conditions which might impair their ability to safely practice medicine. In the absence of a sitting Provider Health Committee the Medical Staff President can be contacted. F. Confidentiality: All reports by third parties and all discussions between a practitioner and the Provider Health Committee or a member thereof shall be kept confidential. The Committee shall report to the Medical Executive Committee, identifying the impaired practitioner anonymously and summarizing the actions recommended by the Committee and the actions taken by the impaired practitioner. These reports shall be maintained in confidence by the Medical Executive Committee in accordance with Maine State Statutes. G. Reportability: Neither the fact that an Impaired practitioner seeks assistance from the Provider Health Committee nor any action undertaken by the practitioner as a result of discussions with the Provider Health Committee shall be reportable to the National Practitioner Data Bank, the Maine Board of Licensure in Medicine, the Maine Board of Osteopathic Licensure or other appropriate licensing board as a disciplinary or adverse clinical privilege action. Likewise, as long as the Impaired practitioner has cooperated with the Provider Health Committee, such matters shall not be reportable by the Provider Health Committee to any other committee or officer of the Medical Staff or York Hospital/ However, the fact that a practitioner seeks assistance or enters into a treatment program shall not preclude an investigation and possible adverse action by other appropriate or Medical Staff committees or officers under the Medical Staff Bylaws. H. Subsequent Action: Report to the President of the Medical Staff or Chief Executive Officer: If a practitioner who is suspected of being impaired has refused to cooperate with the Provider Health Committee or has declined to accept the assistance or recommendations of the Committee, the Committee shall report its findings and its recommendations to the President of the Medical Staff or the Hospital President . The Medical Staff President and/or Hospital President shall meet with the practitioner to discuss the matter. I. Action by Medical Staff President and/or Hospital President: If the practitioner still refuses to accept the recommendations of the Provider Health Committee, the Medical Staff President and/or Hospital President may recommend one or more of the following actions: 1. A requirement that the practitioner undergo treatment as a condition of continued Medical Staff privileges; 2. Restrictions on the practitioner’s clinical privileges; 3. Suspension or termination of the provider’s Medical Staff membership; 4. A request that the practitioner be evaluated by a provider or other appropriate health care professional, selected by the Hospital, who is not a member of the Hospital’s Medical Staff; 5. A requirement that the practitioner submit periodic health status reports from his/her personal provider or health care professional, certifying that the practitioner remains able to safely practice medicine; or 6. No further action. Reinstatement: A member of the Medical Staff who has taken a leave of absence, due to impairment, from the Medical Staff either voluntary or involuntary, or who has been suspended from the Medical Staff, must submit a request for reinstatement. The following information will be requested by the Hospital President and/or Credentials Committee: 1. A letter from an involved treatment center which covers the following: a) Description of the impairment; b) Current status of the impairment; c) Description of the treatment, and d) Statement of the long term prognosis. 2. A letter from the impaired staff member’s personal provider covering the four points listed in (1) above and: a) Personal provider’s opinion of the effect of impairment on Staff Member’s professional performance; b) Personal provider’s statement that the impairment has been treated and that no adverse impact is anticipated; and c) Any additional pertinent information. 3. A letter from the impaired Staff Member which covers the following: a) Description of the impairment; b) Provider’s opinion as to whether the impairment is treated and whether professional performance has been affected; and c) Statement that Staff Members will accept periodic medical evaluations at the request of Administration, Medical Staff President, Credentials Committee. Board of Trustees and/or the appropriate department chiefs. The evaluation is to be performed by a provider qualified by education, training and experience to care for an individual with the condition for which the impaired staff member was treated, who has been chosen by or is acceptable to York Hospital. A member of the Medical Staff who has taken a leave of absence, due to impairment, from the Medical Staff either voluntary or involuntary, or who has been suspended from the Medical Staff, must submit a request for reinstatement. The following information will be requested by the Hospital President and/or Credentials Committee: 1. A letter from an involved treatment center which covers the following: a) Description of the impairment; b) Current status of the impairment; c) Description of the treatment, and d) Statement of the long term prognosis. 2. A letter from the impaired staff member’s personal provider covering the four points listed in (1) above and: a) Personal provider’s opinion of the effect of impairment on Staff Member’s professional performance; b) Personal provider’s statement that the impairment has been treated and that no adverse impact is anticipated; and c) Any additional pertinent information. 3. A letter from the impaired Staff Member which covers the following: a) Description of the impairment; b) Provider’s opinion as to whether the impairment is treated and whether professional performance has been affected; and c) Statement that Staff Members will accept periodic medical evaluations at the request of Administration, Medical Staff President, Credentials Committee, Board of Trustees and/or the appropriate department chiefs. The evaluation is to be performed by a provider qualified by education, training and experience to care for an individual with the condition for which the impaired staff member was treated, who has been chosen by or is acceptable to York Hospital. Q. York Hospital may request periodic status reports covering all points in item (2) above. R. York Hospital will have the right to evaluate the impaired Staff Member for a period of time after the Staff Member is reinstated to the Medical Staff. S. If at any point during the process of evaluation, rehabilitation or reinstatement the provider refuses/fails to comply with this procedure he/she may be summarily suspended in accordance with the standards and procedures established in the Bylaws ... .” On 01/09/2025 at 11:02 AM, Doctor #1 stated the following during an interview: - We had an impaired provider but [he/she] is no longer on staff; - This was back in July and [he/she] ended up taking time off; - [He/She] got letters of support and returned to patient care and then didn’t show up for the shift; and - [He/She] was employed by the hospital. On 01/09/2025 at 1:06 PM, nine (9) Medical Staff were chosen and their credentialing files were reviewed with the Medical Staffing Office Coordinator. The following was identified when Doctor #9’s credentialing file was reviewed: - The Director of Quality stated there are no quality files for the medical staff; - The Medical Staffing Office Coordinator stated she had heard there was a concern but did not receive any information about that; - She heard through the grapevine a concern that [Doctor #9] wasn’t able to be located [by staff] in the ED; - She heard that when [Doctor #9] was located there was additional questioning about whether [he/she] was under the influence; - It was determined that [he/she] was not but I don’t know how that was decided; - This occurred between February through May [of 2024]; - She deactivated [him/her] in the database because she received information from Human Resources; and - They stated that it was an ending of [his/her] contract, but is not sure when that happened. On 01/10/2025 at 8:50 AM, the Chief Human Resources Officer, Director of Compliance and Privacy, Medical Staff President (as of 09/2024) and the Chief Executive Officer were interviewed by a surveyor and Physician Consultant surveyor in regard to Doctor #9. On 01/10/2025 at 9:17 AM, the Chief Human Resources Officer stated: - This situation happened in March of 2024; and - There is no question of [his/her] impairment. The timeline for Doctor #9, per the Chief Human Resources Officer, is as follows: - On 03/18/2024, nursing leadership completed a “York Hospital Provider Incident Form” stating that on that day, Doctor #9 could not be located for approximately forty-five (45) minutes during the scheduled shift; - Eventually, [he/she] was located but staff felt [he/she] appeared slightly disheveled and seemed “off”; - Later that same day, the Chief Human Resources Officer, the Chief Administrator and the nurse leader met with Doctor #9; - [He/She] admitted to leaving the unit to “take a break” but will not do that again without notifying staff; - “No further action” was noted; - On 05/09/2024 at 2:07 PM, an email from Doctor #9’s [supervisor] was sent to the (former) Chief Medical Officer; - The supervisor stated, in part, that he was notified of Doctor #9 calling out for several shifts in a row due to sickness; - He stated that Doctor #21 was called by Doctor #9. Doctor #21 expressed concerns about [him/her] and getting possible help for drug or alcohol problems; - Doctor #20 remained concerned about Doctor #9’s conduct; - In the email, he also noted that another staff member came forward on 05/01/2024, stating that when they were talking with Doctor #9, the smell alcohol was present; - Doctor #9 worked at the hospital on the following days in May (05/01/2024, 05/16/2024 - 05/18/2024, 05/20/2024, 05/26/2024 - 05/28/2024 and 05/31/2024), for a total of ten (10) shifts; - On 05/29/2024 at 12:42 PM, the (former) Chief Medical Officer sent an email to Chief Human Resources Officer, the Chief Administrator and the Human Resources Director; - He stated that he was made aware that morning that a staff member noticed that Doctor #9 had facial flushing and smelled of alcohol on Sunday [05/26/2024] while working with patients, but was not escalated further; - There were concerns about the clinical decision making for a patient he would bring it forward to the (former) Medical Staff President; - Following that email, there was no documented evidence that the Medical Staff Office was made aware of any concerns for patient care related to the possible impairment of Doctor #9; - Doctor #9 continued to work at the hospital, caring for patients on the following days in June and early July (06/01/2024 - 06/04/2024, 06/07/2024 - 06/11/2024, 06/14/2024, 06/16/2024 - 06/18/2024, 06/21/2024, 06/24/2024, 07/01/2024, 07/07/2024 and 07/09/2024), for a total of eighteen (18) shifts; - On 07/18/2024, the Chief Human Resources Officer called Doctor #9 in regard to what was going on for [him/her]; - In part, it was noted that Doctor #9 was dealing with “bouts of alcohol”, “anxiety”, it was not the job [he/she] signed up for and did not think that [he/she] could do the job anymore; - Following the phone call where Doctor #9 confirmed that [he/she] was unable to care for patients, there was no documented evidence that the Medical Staff Office was made aware; - Doctor #9 was told to take some time off; - On 08/14/2024, Doctor #9 provided a letter from his Doctor stating that [he/she] was safe to return to work without restrictions; - Doctor #9 continued to work at the hospital, caring for patients on the following days in August (08/18/2024 - 08/20/2024 and 08/26/2024 - 08/27/2024), for a total of five (5) shifts; and - The last shift Doctor #9 worked was on 08/27/2024, with no documented evidence of any concerns or documented discussions in his credential file; - There was no documented evidence that the Human Resources Department or the Chief Executive Officer of the hospital relayed any concerns to the Medical Staff Office and could not show evidence that the Medical Staff Bylaws for a possibly impaired Doctor were followed; and - The Chief Executive Officer stated that he sent in some information to the Maine Board of Medicine but could not recall when that was done but was able to show that the Maine Board of Medicine received the information on 09/09/2024. On 01/10/2025 at 9:43 AM, the Director of Compliance and Privacy confirmed there was no committee that was initiated, as required per the bylaws. On 01/10/2025 at 9:49 AM, the Medical Staff President (as of 09/2024) stated that the [Medical Staff President] needs to be made aware of this type of situation. On 01/10/2025 at 9:59 AM, the Chief Executive Officer stated that [the Director of the Department for Doctor #9] was fully aware. When asked if the Medical Staff President was notified of this situation with Doctor #9, he stated that he doesn’t have anything in his files about speaking to [the Medical Staff President]. When asked if he agreed that the Medical Staff President would need to be made aware of a physician who is impaired, he stated, “You are probably accurate, but I would have to go check the bylaws.” The AdHoc/Provider Health Committee, appointed by the Chair of the Medical Executive Committee, were not aware of any concerns and could therefore, not initiate the proper review. There were also several Doctor’s involved who were aware of Doctor #9’s impairment and did not bring their concerns, as encouraged in the bylaws, to the Medical Staff President and/or the Hospital President. Hospital leadership and Human Resources were aware for approximately one hundred and ten (110) days that Doctor #9 was caring for patients at the hospital during thirty-three (33) shifts knowing the significant concerns regarding [his/her] impairment.”

“MEDICAL STAFF - SELECTION CRITERIA CFR(s): 482.12(a)(6) [The governing body must] ensure that criteria for selection are individual character, competence, training, experience, and judgement. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the Governing Body failed to ensure that the Medical Staff’s credentialing file contained the following: Peer review and periodic appraisals for application approval for nine (9) of nine (9) files reviewed (Doctor #1, #6, #9, #17 - #20, Nurse Practitioner (“NP”) #1 and #2). Findings: The “York Hospital Medical Staff Bylaws and Regulations”, last revised in 05/2019 states, in part, “All those eligible under these Bylaws, who have delineated clinical privileges, and who seek to have patient care responsibilities, must make application for appointment and reappointment to either the Medical Staff. Appointments and reappointments are the legal right and responsibility of the Board of Trustees of the Hospital and will be based on the findings and recommendations of the Bylaws & Credentials Committee and the Medical Executive Committee. The Board may appoint only those practitioners who are judged by their peers to be of good character, qualified, and competent in their respective fields. Application for membership on the Staff shall be presented in writing on a prescribed form which shall state the qualifications and references of the applicant and also signify his or her agreement to abide by the Bylaws, Rules & Regulations, and Policies & Procedures of the Staff and the Hospital as they may then exist or may be amended from time to time. In the process of the initial application for appointment, and in subsequent applications for reappointment, the applicant shall provide personal attestations, and give permission for the Hospital to obtain the following information (from the primary source whenever feasible): 1. Primary verification for appointment and reappointment includes: ... 7. Three peer references regarding clinical skills and competence. At reappointment, two peer references regarding clinical skills and competence ... 15. Results of Hospital review of any patient, staff or professional complaints and review of any notification given to the practitioner or disciplinary actions taken related to such review. 16. Review of quality measures. 17. Record of professional performance and conduct at other institutions where the individual holds, or has held, privileges to practice.” In addition, “The completed application, with supporting documents, shall be forwarded to the Medical Staff Office. After the application has been processed and verifications completed, the Department Chief of the Department in which the applicant seeks clinical privileges will review the application to determine if he or she meets the criteria of education, training, and experience for membership and the clinical privileges requested and make his or her recommendation. The application and all supporting material shall then be sent to the Bylaws and Credential Committee for evaluation and recommendation. Each recommendation concerning the reappointment of a Staff member and the clinical privileges to be granted upon reappointment shall be based upon such member’s professional competence and clinical judgment in the treatment of patients, his or her compliance with the Bylaws, Rules & Regulations and Policies & Procedures, quality of care, peer review, participation in required Medical Staff activities, professional behavior and citizenship, ethics, medical records quality, continuing education, and on the information collected pursuant to items 1 through 17 specified previously in Section 6 of this Article. On 01/08/2025 at 8:46 AM, Doctor #1 was interviewed in regard to the credentialing process. The following was stated: - I couldn’t find evidence of [Ongoing Professional Practice Evaluation] “OPPE” [This identifies professional practice trends that may impact the quality and safety of care and applies to all practitioners granted privileges via the Medical Staff chapter requirements] or [Focused Professional Practice Evaluation] “FPPE” [A process whereby the medical staff evaluates the privilege-specific competence of the practitioner that lacks documented evidence of competently performing the requested privilege(s) at the organization]; - We really need to execute the OPPE and FPPE; - As far as any ongoing reporting, I have not seen that information; - For new candidates, there is a page application, verifications, and the usual housekeeping actions that are done; - Evaluations for new Medical Staff, I don’t feel like it happened: - When I came on board, I had completed three (3) or (6) months, and no feedback was provided; - I can’t say as though I recall seeing anything specific for quality for the providers file since their last credentialing; and - The credentialing and re-credentialing needs to be more robust, as there is no chair signature. On 01/09/2025 at 9:02 AM, Doctor #4 was interviewed. He stated the following: - I have never worked in a place that doesn’t have OPPE and FPPE; and - I look at it as an opportunity as doing things that we have not seen done at this institution. On 01/09/2025 at 1:06 PM, nine (9) Medical Staff were chosen and their credentialing files were reviewed with the Medical Staffing Office Coordinator. There was no documented evidence of the following in nine (9) of nine (9) of the Medical Staff files: - Results of a hospital review of any patient, staff or professional complaints and review of any notification given to the practitioner or disciplinary actions taken related to such review; and - Record of professional performance and conduct at other institutions where the individual holds, or has held, privileges to practice. On 01/09/2025 at approximately 1:15 PM, the Director of Quality stated the following in regard to the requirements for their peer reviews, professional performance or notifications of any disciplinary actions in their credentialing file, which the hospital refers to as the “Quality File”: - As far as the quality file for providers, we don’t have any quality files. We don’t have those programs set up and we don’t have a process set up; - I have been here two years and we have not done any OPPE’s or FPPE’s; - We have no data to provide for at least the last two (2) years; and - We do have letters from peer review, I do not know what they are for and I don’t recall ever using them for credentialing. On 01/09/2025 at 2:37 PM, the Medical Staffing Office Coordinator was asked how she knew that the Medical Staff were qualified for the privileges they were requesting at the hospital. She said, “I don’t have an answer for that.””

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 46424 Based on document reviews and interviews, the hospital failed to provide a written notice of its determination regarding a grievance in accordance with their policy for three (3) of five (5) patients reviewed who filed grievances (Patients 1G, 4G, and 5G). Findings: The hospital’s “Patient Complaints and Grievances” policy and procedure, last approved 12/2024, states in part, “To establish procedures to respond, review and resolve patient grievances and complaints as required by the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation. CMS defines a grievance as a written or verbal complaint, not resolved at the time of the complaint by the staff present, regarding the patient’s care, abuse or neglect, issues related to compliance with the CMS Conditions of Participation.” The procedure for responding is defined, in part, “A written (email/mail) acknowledgement to the patient or patient’s representative within 7 business days of receipt of the written grievance and/or conversation with patient or representative...and a written (email/mail) response will be given to the patient or representative within 30 business days from date of receipt.” 1. On 1/22/2024, the hospital received a grievance from Patient 1G. As of 1/13/2025, there was no evidence of written a written response and determination within thirty (30) business days of receipt of the grievance. 2. On 11/18/2024, the hospital received a grievance from Patient 4G. As of 1/13/2025, there was no evidence of a written response and determination within thirty (30) business days of receipt of the grievance. 3. On 11/18/2024, the hospital received a grievance from Patient 5G. As of 1/13/2025 there was no evidence of a written response and determination within thirty (30) business days of receipt of the grievance. On 1/10/2025 at 9:45 AM, the Compliance and Privacy Director confirmed that the hospital had failed to comply with its policy on the above grievances.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(4) Training documentation. The hospital must document in the staff personnel records that the training and demonstration of competency were successfully completed. This Standard is not met as evidenced by: 46424 Based on document reviews and interviews, the hospital failed to ensure medical and nursing staff, who were involved in patient restraints, had completed the required restraint training for six (6) of six (6) doctors and three (3) of nine (9) who were involved with patient restraints (Doctor #10 - #15) (Registered Nurses #1 - #3). Findings: The hospital’s “Use of Restraints for Non-Violent/Non Self-Destructive Behaviors” policy and “Use of Restraints for Violent/Self-Destructive Behaviors” policies, last approved in 1/2022, both state in part for providers, “Providers ordering restraints will receive restraint education according to medical staff bylaws and the current policy during Medical Staff Orientation with the Quality & Risk Department and/or Healthstream. Restraint training will be provided through HealthStream or face to face with the education department to any caregiver responsible for applying restraints,” and for staff, “On-going training and evaluation for competency of the assessment/reassessment, safe use, application and release occurs annually for all staff who applies restraints.” 1. Doctor #10 and Doctor #11 were involved in the care of the following patient who was restrained: - Patient 1R was in restraints from 1/04/2024 - 1/05/2024. Violent restraints were applied at 4:30 AM on 1/04/2024 and removed at 11:00 AM on 1/04/2024. Non-violent restraints were then applied at 11:00 AM on 1/04/2024 and removed at 9:30 AM on 1/05/2024. The surveyor requested to review the restraint training records of Doctor #10 and Doctor #11. As of 1/13/2025, there was no evidence provided to the surveyor that indicated Doctor #10 and Doctor #11 had completed annual training on restraints. 2. Doctor #12, Doctor #13 and Registered Nurse (“RN”) #1 were involved in the care of the following patient who was restrained: - Patient 2R was in restraints from 7/09/2024 - 7/10/2024. Non-violent restraints were applied at 5:30 PM on 7/09/2024 and removed at 10:00 AM on 7/10/2024. The surveyor requested to review the restraint training records of Doctor #12, Doctor #13 and RN #1. As of 1/13/2025, there was no evidence provided to the surveyor that indicated Doctor #12, Doctor #13 and #4 and RN #1 had completed annual training on restraints. 3. Doctor #14 was involved in the care of the following patients who were restrained: - Patient 3R was in restraints on 9/28/2024. Non-violent restraints were applied at 6:40 AM on 9/28/2024 and removed at 9:21 AM on 9/28/2024. - Patient 4R was in restraints on 6/30/2024. Non-violent restraints were applied at 1:00 PM on 6/30/2024 and removed at 9:00 PM on 6/30/2024. - Patient 5R was in restraints on 12/28/2024. Violent restraints were applied at 8:17 PM on 12/28/2024 and removed at 10:40 PM on 12/28/2024. RN #2 and RN #3 were also involved in the care of Patient 4R who was in restraints on 6/30/2024. The surveyor requested to review the restraint training records of Doctor #14 and RN #2 and RN #3. As of 1/13/2024, there was no evidence provided to the surveyor that indicated Doctor #14, RN #2, and RN #3 had completed annual training on restraints. 3. Doctor #15 was involved in the care of Patient 5R who was in restraints on 12/28/2024. The surveyor requested to review the restraint training records of Doctor #15. As of 1/13/2025, there was no evidence provided to the surveyor that indicated Doctor #15 had completed annual training on restraints. On 1/13/2025 at 11:40 AM, the Chief Nursing Officer confirmed that Doctor #10 - Doctor #15 and RN’s #1 - #3 were not in compliance with hospital policy regarding restraint training.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure that it incorporated quality indicator data into the hospital’s Quality Assessment and Performance Improvement (“QAPI”) Program. Findings include: The “York Hospital QAPI Plan” for 2024 states, in part, “Data collection is the basis for all performance improvement activities and provides a means of measuring performance through which informed decisions can be made. Data is collected for a comprehensive set of performance measures based on a priority basis in order to: o Establish a baseline when a process is implemented or redesigned o Identify the process performance measure o Describe the dimensions of the performance relevant to functions, processes, and outcomes o Identify areas for improvement including patient outcomes o Determine if the changes in a process have met the objectives o Implement a strategy for maintaining the effectiveness of the redesigned process over time o Collect data as a part of continuing measurement and work prioritization, and may include process and outcomes measures Performance measurements (indicators) data obtained through: o Use of process or outcome indicators (as part of monitoring and evaluation activities), utilization and financial monitors, and adverse-event or occurrence monitors. o Benchmarking or comparative data, such as local, state, regional, or national utilization patterns related to specific procedures, mortality rates and aggregated clinical outcome compliance rates. o Studies or continuous monitoring of the cost of poor quality, patient and staff complaints and recommendations, and focus-group findings on the community’s perception of the cost and quality of York Hospital services.” In addition, “The Quality Department will assist with the coordination of data, which is available throughout the facility in order to develop a consistent flow of information. All designated services of the hospital and Medical Staff will be responsible for participating in the data collection processes for each of their key performance areas and quality improvement projects. When high volume cases are sampled, an appropriate sample size is to be determined and used.” “The organization has a systematic process for assessing the collected data (measurement) in order to determine whether the newly designed processes result in performance improvements. The assessment will look at the performance of the process over time and make comparisons to external resources as appropriate. Ultimately, the assessment will determine the success of performance improvement by: identifying if new processes have met the elements of design. Identifying whether existing processes are stable and meet the level of expected performance. Assisting in setting priorities for opportunities of improvement in existing processes. Evaluating the effects of changes in the process to determine if improvements have resulted in the desired outcome or resulted in undesirable variations in performance. Comparing statistical data over time to determine if collection is systematic and accurate. Reviewing situations where the assessment of the data reveals a problem with individual performance; The medical staff or department leader uses the findings according to the medical staff bylaws, rules and regulations, or other appropriate human resource guidelines.” 01/09/2025 11:20 AM, the Director of Quality was asked about the reporting of QAPI data. He stated they only report when he asks for the data, he tries to have them report yearly. He also stated he recognizes that they have a problem here with the way things are done here. He further stated they had a quality control person but since they left the facility, they are struggling to rebuild the program. 01/09/2025 1:05 PM, the Administrative Director of Laboratory Services was asked about QAPI. He stated that the only time data they have been tracking is reported to Quality is when they ask for it. He was unaware if the data submitted was represented at the QAPI meetings.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure that Quality Assessment and Performance Improvement (“QAPI”) program activities were set based on high-risk, high-volume, or problem-prone areas that affect health outcomes and patient care. There was no evidence that they considered the incidence, prevalence, and severity of problems in those areas. Findings: The “York Hospital QAPI Plan” for 2024 states, in part, “All areas of the organization will take a systematic approach for identifying trends, problems, or variations in services. The leaders of the service and staff members are responsible for setting priorities to improve already well operating processes, or to reduce variation or eliminate undesirable outcomes in current processes. The primary focus will be on those processes that need to be improved with high risk, high volume, or problem prone. Additionally, areas with new process, technologies or changes in the standard of care may also be areas of focus. In cases where priorities need to be set, assistance may be obtained from the Quality Committee or the service’s leader. When opportunities for improvement of performance are determined, an action plan should reflect the following items: o Identification of the process to be improved and establishment of priorities if more than one process for improvement has been identified. o Comparison of improvement plan to the organization’s mission and goals/objectives for conformity. o Determination of whether the action requires testing. If testing is required, a strategy will be formulated which addresses how, when, where, and by whom. o Assessment of the data following testing or action to determine if change has improved the performance or if a new design is necessary. o Determination of the line of responsibility for implementation of the improvement (ultimately the responsibility lies with the organization’s leaders to ensure that improvement has been accomplished.).” On 01/08/2025 at 11:38 AM, the Director of Quality was asked about the scope of their projects and stated the following: - Invasive cardiology is done at York Hospital and would be considered the most dangerous for patients; and - There have been no performance improvement activities in that area. On 01/08/2025 at 1:04 PM, Doctor #2 stated the following in regard to improvement projects: - Our Quality Department has had a lot of [staff] losses; - It is hard to devote time to quality projects; - We have wanted to start a few but we have not been able to get it off the ground; - We need to know how to get one going; - It has been two (2) or three (3) years [since we have had projects]; and - It is probably a lower priority than it has ever been. On 01/09/2025 at 8:45 AM, the Director of Quality stated that Provider projects “Didn’t happen”. On 01/13/2025 at 3:11 PM, the Chief Nursing Officer was asked about projects. She confirmed that they have an opportunity in that area.”

“QAPI PERFORMANCE IMPROVEMENT PROJECTS CFR(s): 482.21(d) As part of its quality assessment and performance improvement program, the hospital must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must be proportional to the scope and complexity of the hospital’s services and operations. (2) A hospital may, as one of its projects, develop and implement an information technology system explicitly designed to improve patient safety and quality of care. This project, in its initial stage of development, does not need to demonstrate measurable improvement in indicators related to health outcomes. (3) The hospital must document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. (4) A hospital is not required to participate in a QIO cooperative project, but its own projects are required to be of comparable effort. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure that the Quality Assessment and Performance Improvement (“QAPI”) identified Performance Improvement projects in 2024. Findings include: The “York Hospital QAPI Plan” for 2024 states, in part, “To fulfill this commitment, the Quality Assurance and Performance Improvement (QAPI) plan at York Hospital is designed to assess patient care and other support processes important to health and safety in a systematic, ongoing manner, identify improvement opportunities, and to develop action plans and interventions in a timely manner. This organization-wide written plan provides guidance for York’s overall quality improvement program, including identifying and implementing opportunities to improve the quality of care, as well as other measures of organizational performance.” In addition, “Performance Improvement plans that have been approved by the Quality Committee will have action plans that have been tested or implemented, and the results are to be communicated at least annually to the Quality Committee. If the action has been determined to be ineffective, a new action is to be planned and tested. To coordinate the performance improvement information activities throughout the hospital, the Quality and Risk Management Department will have access to and receive all performance improvement activities information. The Chairperson of each committee, the Medical Staff department President, and Leaders will share information among the appropriate patient services, committees, professionals, and/or leadership in the hospital/Medical Staff when applicable. The Chairperson of the Quality Committee or designee will report performance improvement activities to the Medical Executive Committee through the Quality Committee minutes annually. Based in part upon the annual reappraisal report prepared by the Quality Department, the Quality Committee will conduct a review of the Quality and Patient Safety Plan on an annual basis. This will include a review of the distinct performance improvement projects being conducted, the reasons for conducting these projects, and measurable progress achieved. The evaluation of the plan’s effectiveness will be documented in the minutes. Specific recommendations will be sent to all applicable committees, Medical Staff departments and patient services in the organization as needed.” On 01/08/2024, the Quality Improvement data was reviewed. The following was identified: - There are five (5) areas in which data is being reviewed (Length of Stay, Sepsis, Hand Hygiene, Falls and Ambulatory Access); and - There was no documented evidence of Performance Improvement projects. On 01/08/2025 at 3:07 PM, Doctor #3 was asked about performance improvement projects. He/She stated that we are looking to have a formal process for performance improvement. As it is, I don’t believe that it exists. On 01/09/2025 at 9:02 AM, Doctor #4 was asked about performance improvement projects. He/She stated, “Unfortunately, there has not been any dedicated Quality Improvement.” On 01/09/2025 at 11:02 AM, Doctor #6 was asked about performance improvement projects. He/She stated they were a recent hire but was not aware of [performance] initiatives prior to my arrival. 01/09/2025 11:20 AM, the Director of Quality was asked about performance improvement projects. He stated that the projects are tracking the Length of Stay, Sepsis, Ambulatory Access, Falls, and Hand Hygiene. On 01/13/2025 at 3:11 PM, the Chief Nursing Officer was asked about performance improvement projects. She confirmed that they have an opportunity in that area.”

“QAPI GOVERNING BODY, STANDARD TAG CFR(s): 482.21 ... The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement) ... The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital’s Governing Body failed to ensure that the Quality Assessment and Performance Improvement (“QAPI”) Program reflects the complexity of the hospital’s organization and services and involves all hospital department and services (including those services furnished under contract or arrangement). Findings include: The “York Hospital QAPI Plan” for 2024 states, in part, “The Board of Trustees of York Hospital bears the ultimate responsibility for assuring the quality and effectiveness of patient care services provided by the medical staff members, clinical staff, and support staff. o The Board will ensure that the improvement program reflects the complexity of the hospital’s organization and services; that it involves all hospital departments and services; and focuses upon indicators related to improved health outcomes and the prevention and reduction of medical errors. o The Board of Trustees must ensure that the hospital-wide quality and performance improvement program efforts address priorities for improved quality of care and patient safety; and all improvement actions are evaluated. o The Board of Trustees will require that objective measures be used to gauge the quality of care and services are provided. o The Board of Trustees will receive reports of hospital- wide performance improvement activities; they will review the findings, actions and results from the performance improvement activities in order to assess the plan’s efficiency and effectiveness. o The Board of Trustees will allocate adequate resources for measuring, assessing, also improving, and sustaining performance in key quality processes. Also reducing risk to patients through assignment of personnel and providing adequate time for personnel to participate in performance improvement activities. Adequate information services and data management systems will be supplied to facilitate collection and analysis of data. o The Board of Trustees will assure training and education to all Leaders, and subsequently their staff, on the processes that contribute to improved patient safety and patient outcomes.” On 01/09/2024, the Board of Trustees minutes, provided for 2024, were reviewed. The following was identified: - On 02/29/2024, it was noted that Board of Trustee #1 was the Chairman of the Quality Committee; - On 04/25/2024, Board of Trustee (“BOT”) #1 stated that in regard to QAPI, they have been talking about structure as they reassess and move forward and that the[QAPI] minutes reflect the ongoing success of this approach; - On 06/27/2024, BOT #1 stated that the [QAPI] minutes are available in the Board Packet; - On 08/29/2024, BOT #1 was absent but the Chief Nursing Officer (“CNO”) stated that the [QAPI] minutes are available in the Board Packet; and - On 10/31/2024, BOT #1 stated that the minutes are very thorough and review our discussions and presentations. It is very positive to know a number of benchmarks are being used to measure our quality measures. There was no documented evidence that the Governing Body discussed the QAPI program in any of the meetings, other than being provided the Hospital Quality Committee Minutes. On 01/09/2024, the Hospital Quality Committee (“HQC”) minutes, provided for 2024, were reviewed. The following was identified: - On 01/09/2024, the HQC was informed of the proposed 2024 goals, including: Hospital-wide length of stay, Hospital-wide Sepsis CMS Bundle Compliance, Hand Hygiene compliance, Hospital Falls reduction, and Improve Ambulatory Access; - On 02/13/2024, the HQC was provided information on the five (5) areas they are monitoring; - On 03/12/2024, the HQC was provided information on one (1) of the areas they are monitoring; - On 04/09/2024, the HQC was provided information on the five (5) areas they are monitoring; - On 05/14/2024, the HQC was provided information on three (3) areas they are monitoring, however there was a request from a committee member that there be an outpatient discussion on quality initiatives; - On 06/14/2024, the HQC was provided information on the five (5) areas they are monitoring; - On 08/13/2024, the HQC was told that their QAPI updates and performance reports were going to be sent via email; - On 09/10/2024, the HQC was told that their QAPI updates and performance reports were going to be sent via email; - On 10/07/2024, the HQC was provided information on four (4) of the five (5) areas they are monitoring; and - On 12/10/2024, the HQC was provided information on four (4) of the five (5) areas they are monitoring. Throughout the HQC minutes for 2024 that were provided, there was no documented evidence that BOT #1 attended an HQC meeting or participated in any way. On 01/09/2025 at 11:29 AM, Doctor #7 was interviewed in regard to QAPI for a contracted service. The following was identified: - Well, we don’t do a lot; - We had locums and staffing issues and then we have had a little trouble getting into the system but we do have some of the peer review information; and - I am not aware of reporting to Quality. On 01/13/2025 at 2:45 PM, the CNO stated that she thinks they are conducting [Performance Improvement] PI, but thinks they need to streamline the data.”

“QAPI EXECUTIVE RESPONSIBILITIES CFR(s): 482.21(e)(1), (e)(2), (e)(5) The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: 1) That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained . (2) That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. (5) That the determination of the number of distinct improvement projects is conducted annually. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to provide documented evidence that the Governing Body has taken full responsibility for the hospital-wide Quality Assessment and Improvement Process (“QAPI”) Program. Findings: The “York Hospital QAPI Plan” for 2024 states, in part, “The Board of Trustees of York Hospital bears the ultimate responsibility for assuring the quality and effectiveness of patient care services provided by the medical staff members, clinical staff, and support staff. o The Board will ensure that the improvement program reflects the complexity of the hospital’s organization and services; that it involves all hospital departments and services; and focuses upon indicators related to improved health outcomes and the prevention and reduction of medical errors. o The Board of Trustees must ensure that the hospital-wide quality and performance improvement program efforts address priorities for improved quality of care and patient safety; and all improvement actions are evaluated. o The Board of Trustees will require that objective measures be used to gauge the quality of care and services are provided. o The Board of Trustees will receive reports of hospital- wide performance improvement activities; they will review the findings, actions and results from the performance improvement activities in order to assess the plan’s efficiency and effectiveness. o The Board of Trustees will allocate adequate resources for measuring, assessing, also improving, and sustaining performance in key quality processes. Also reducing risk to patients through assignment of personnel and providing adequate time for personnel to participate in performance improvement activities. Adequate information services and data management systems will be supplied to facilitate collection and analysis of data. o The Board of Trustees will assure training and education to all Leaders, and subsequently their staff, on the processes that contribute to improved patient safety and patient outcomes.” The Bylaws of York Hospital, last reviewed 08/26/2021, states in part, “Members of the Board of Trustees are expected to attend 75% of Committee meetings. The administrative office will maintain an attendance record for each Committee meeting. Attendance at Full Board and Committee meetings will be reviewed annually by the Executive Committee to determine continued service on the Board.” On 01/09/2024, the Board of Trustees minutes, provided for 2024, were reviewed. The following was identified: - On 02/29/2024, it was noted that Board of Trustee #1 was the Chairman of the Quality Committee; - On 04/25/2024, Board of Trustee (“BOT”) #1 stated that in regard to QAPI, they have been talking about structure as they reassess and move forward and that the[QAPI] minutes reflect the ongoing success of this approach; - On 06/27/2024, BOT #1 stated that the [QAPI] minutes are available in the Board Packet; - On 08/29/2024, BOT #1 was absent but the Chief Nursing Officer (“CNO”) stated that the [QAPI] minutes are available in the Board Packet; and - On 10/31/2024, BOT #1 stated that the minutes are very thorough and review our discussions and presentations. It is very positive to know a number of benchmarks are being used to measure our quality measures. There was no documented evidence that the Governing Body discussed the QAPI program in any of the meetings, other than being provided the Hospital Quality Committee Minutes. On 01/09/2024, the Hospital Quality Committee (“HQC”) minutes, provided for 2024, were reviewed. The following was identified: - On 01/09/2024, the HQC was informed of the proposed 2024 goals, including: Hospital-wide length of stay, Hospital-wide Sepsis CMS Bundle Compliance, Hand Hygiene compliance, Hospital Falls reduction, and Improve Ambulatory Access; - On 02/13/2024, the HQC was provided information on the five (5) areas they are monitoring; - On 03/12/2024, the HQC was provided information on one (1) of the areas they are monitoring; - On 04/09/2024, the HQC was provided information on the five (5) areas they are monitoring; - On 05/14/2024, the HQC was provided information on three (3) areas they are monitoring, however there was a request from a committee member that there be an outpatient discussion on quality initiatives; - On 06/14/2024, the HQC was provided information on the five (5) areas they are monitoring; - On 08/13/2024, the HQC was told that their QAPI updates and performance reports were going to be sent via email; - On 09/10/2024, the HQC was told that their QAPI updates and performance reports were going to be sent via email; - On 10/07/2024, the HQC was provided information on four (4) of the five (5) areas they are monitoring; and - On 12/10/2024, the HQC was provided information on four (4) of the five (5) areas they are monitoring. On 01/13/2025 at 11:00 AM, BOT #2 was interviewed. She stated, in part, the following: - We get reports from leaders, quality, medical executive, nursing, etc. and they keep us informed; - Concerns, in regard to patient care, are not brought to the board level, but it wouldn’t be ignored; and - I do not recall any quality of care concerns. On 01/13/2025 at 11:49 AM, BOT #1 was interviewed. She stated, in part, the following: - I am the current Chair of the BOT and the Chair of the Quality Committee; - In regard to QAPI, all areas of the hospital are reviewed at the meetings; - They have four (4) - five (5) QAPI goals; and - They have a plan to improve the process, for example, hand hygiene. On 01/13/2025 at 2:45 PM, the CNO was asked who oversees the QAPI program to provide evidence of QAPI activities that were initiated based on data reported through the medical error/adverse event tracking system. She stated that the Chief Medical Officer (“CMO”) had responsibility for Quality. Our CMO left and it got shifted to me. In addition, the CNO stated that she thinks they are conducting [Performance Improvement] PI, but thinks they need to streamline the data. Throughout the HQC minutes for 2024 that were provided, there was no documented evidence that BOT #1 attended an HQC meeting or participated in any way, though the expectation is to attend 75% of Committee meetings.”

“ELIGIBILITY & PROCESS FOR APPT TO MED STAFF CFR(s): 482.22(a) The medical staff must be composed of doctors of medicine or osteopathy. In accordance with State law, including scope of practice laws, the medical staff may also include other categories of physicians (as listed at §482.12(c)(1)) and non-physician practitioners who are determined to be eligible for appointment by the governing body. This Standard is not met as evidenced by: 42601 REPEAT DEFICIENCY Based on document reviews and interviews, the hospital failed to ensure that each Medical Staff’s credentialing file contained the required signatures for application approval for nine (9) of nine (9) files reviewed (Doctor #1, #6, #9, #17 - #20, Nurse Practitioner (“NP”) #1 and #2). Findings: During a recent Federal complaint survey (07/11/2024), five (5) of eight (8) Medical Staff credentialing files failed to include a signed Requested Privileges form by Department Chief, Bylaws and Credentials Committee, Medical Executive Committee or Board of Trustees. The plan of correction, signed by the President/Chief Executive Officer on 08/02/2024 stated the following corrective measures: - In order to ensure the Medical Staff Office and subsequently the Medical Staff itself is operating in accordance with its bylaws, the hospital will initiate an audit of all provider files (including Advanced Practice Practitioners) with a 09/06/2024 goal of completion; - Results of this audit will be shared with the Compliance Officer, Executive Leadership, The President of the Medical Staff and Board of Trustees; - Any corrective action steps will be completed immediately upon discovery of a deficiency; - In addition, the Compliance Officer will randomly select and review the Medical Staff Office files of new providers joining the organization 08/04/2024; - Immediate feedback will be provided if any deficiencies are noted with correction required within forty-eight (48) hours; - The Compliance Officer is responsible for implementing this plan of correction. The “York Hospital Medical Staff Bylaws and Regulations”, last revised in 05/2019 states, in part, “All those eligible under these Bylaws, who have delineated clinical privileges, and who seek to have patient care responsibilities, must make application for appointment and reappointment to either the Medical Staff. Appointments and reappointments are the legal right and responsibility of the Board of Trustees of the Hospital and will be based on the findings and recommendations of the Bylaws & Credentials Committee and the Medical Executive Committee. ... The completed application, with supporting documents, shall be forwarded to the Medical Staff Office. After the application has been processed and verifications completed, the Department Chief of the Department in which the applicant seeks clinical privileges will review the application to determine if he or she meets the criteria of education, training, and experience for membership and the clinical privileges requested and make his or her recommendation. The application and all supporting material shall then be sent to the Bylaws and Credential Committee for evaluation and recommendation.” In addition, “The Board shall consider the recommendations for reappointment or non-reappointment and shall direct Administration to notify the applicant, and if reappointed, shall secure his or her signed agreement to be governed by these Bylaws, Rules & Regulations, and Policies & Procedures. In the case of non-reappointment or change in clinical privileges, the Staff member has the right to exercise or waive his or her right to Fair Hearing as provided in the Bylaws of York Hospital. The Board shall not take action (denial, or reduction in privileges) in opposition to MEC recommendation on any reappointment without a prior Joint Conference with the MEC.” On 01/09/2025 at 1:06 PM, nine (9) Medical Staff were chosen and their credentialing files were reviewed with the Medical Staffing Office Coordinator. - There was no documented evidence of signed Requested Privileges form by Department Chief, Bylaws and Credentials Committee, Medical Executive Committee or Board of Trustees for the reviewed Medical Staff. The Medical Staffing Office Coordinator stated the following: - There has been brainstorming. It was in the plan of correction that I was to obtain the signatures; - I wasn’t a part of writing the plan of corrections but was told about it; - We started going back to the beginning to the older files that had not been signed; - COVID changed everything and it sounds bad but I got out of the habit [of getting the required signatures] and haven’t gotten back into that; - It is very important that signatures were completed and that is a function of my role; - I can’t offer an explanation; and - I did not bring the files for them to sign. On 01/09/2025 at approximately 3:00 PM, an interview was conducted with the Director of Compliance and Privacy in regard to the missing signatures. He stated the following: - I started the audit; and - I stopped everything because I realized how badly broken the operation was.”

“MEDICAL STAFF PERIODIC APPRAISALS CFR(s): 482.22(a)(1) The medical staff must periodically conduct appraisals of its members. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure that each Medical Staff’s credentialing file contained the following: Peer review and periodic appraisals for application approval for nine (9) of nine (9) files reviewed (Doctor #1, #6, #9, #17 - #20, Nurse Practitioner (“NP”) #1 and #2). Findings: The “York Hospital Medical Staff Bylaws and Regulations”, last revised in 05/2019 states, in part, “All those eligible under these Bylaws, who have delineated clinical privileges, and who seek to have patient care responsibilities, must make application for appointment and reappointment to either the Medical Staff. Appointments and reappointments are the legal right and responsibility of the Board of Trustees of the Hospital and will be based on the findings and recommendations of the Bylaws & Credentials Committee and the Medical Executive Committee. The Board may appoint only those practitioners who are judged by their peers to be of good character, qualified, and competent in their respective fields. Application for membership on the Staff shall be presented in writing on a prescribed form which shall state the qualifications and references of the applicant and also signify his or her agreement to abide by the Bylaws, Rules & Regulations, and Policies & Procedures of the Staff and the Hospital as they may then exist or may be amended from time to time. In the process of the initial application for appointment, and in subsequent applications for reappointment, the applicant shall provide personal attestations, and give permission for the Hospital to obtain the following information (from the primary source whenever feasible): 1. Primary verification for appointment and reappointment includes: ... 7. Three peer references regarding clinical skills and competence. At reappointment, two peer references regarding clinical skills and competence ... 15. Results of Hospital review of any patient, staff or professional complaints and review of any notification given to the practitioner or disciplinary actions taken related to such review. 16. Review of quality measures. 17. Record of professional performance and conduct at other institutions where the individual holds, or has held, privileges to practice.” In addition, “The completed application, with supporting documents, shall be forwarded to the Medical Staff Office. After the application has been processed and verifications completed, the Department Chief of the Department in which the applicant seeks clinical privileges will review the application to determine if he or she meets the criteria of education, training, and experience for membership and the clinical privileges requested and make his or her recommendation. The application and all supporting material shall then be sent to the Bylaws and Credential Committee for evaluation and recommendation. Each recommendation concerning the reappointment of a Staff member and the clinical privileges to be granted upon reappointment shall be based upon such member’s professional competence and clinical judgment in the treatment of patients, his or her compliance with the Bylaws, Rules & Regulations and Policies & Procedures, quality of care, peer review, participation in required Medical Staff activities, professional behavior and citizenship, ethics, medical records quality, continuing education, and on the information collected pursuant to items 1 through 17 specified previously in Section 6 of this Article. On 01/08/2025 at 8:46 AM, Doctor #1 was interviewed in regard to the credentialing process. The following was stated: - I couldn’t find evidence of [Ongoing Professional Practice Evaluation] “OPPE” [This identifies professional practice trends that may impact the quality and safety of care and applies to all practitioners granted privileges via the Medical Staff chapter requirements] or [Focused Professional Practice Evaluation] “FPPE” [A process whereby the medical staff evaluates the privilege-specific competence of the practitioner that lacks documented evidence of competently performing the requested privilege(s) at the organization]; - We really need to execute the OPPE and FPPE; - As far as any ongoing reporting, I have not seen that information; - For new candidates, there is a page application, verifications, and the usual housekeeping actions that are done; - Evaluations for new Medical Staff, I don’t feel like it happened: - When I came on board, I had completed three (3) or (6) months, and no feedback was provided; - I can’t say as though I recall seeing anything specific for quality for the providers file since their last credentialing; and - The credentialing and re-credentialing needs to be more robust, as there is no chair signature. On 01/09/2025 at 9:02 AM, Doctor #4 was interviewed. He stated the following: - I have never worked in a place that doesn’t have OPPE and FPPE; and - I look at it as an opportunity as doing things that we have not seen done at this institution. On 01/09/2025 at 1:06 PM, nine (9) Medical Staff were chosen and their credentialing files were reviewed with the Medical Staffing Office Coordinator. There was no documented evidence of the following in nine (9) of nine (9) of the Medical Staff files: - Results of a hospital review of any patient, staff or professional complaints and review of any notification given to the practitioner or disciplinary actions taken related to such review; and - Record of professional performance and conduct at other institutions where the individual holds, or has held, privileges to practice. On 01/09/2025 at approximately 1:15 PM, the Director of Quality stated the following in regard to the requirements for their peer reviews, professional performance or notifications of any disciplinary actions in their credentialing file, which the hospital refers to as the “Quality File”: - As far as the quality file for providers, we don’t have any quality files. We don’t have those programs set up and we don’t have a process set up; - I have been here two years and we have not done any OPPE’s or FPPE’s; - We have no data to provide for at least the last two (2) years; and - We do have letters from peer review, I do not know what they are for and I don’t recall ever using them for credentialing. On 01/09/2025 at 2:37 PM, the Medical Staffing Office Coordinator was asked how she knew that the Medical Staff were qualified for the privileges they were requesting at the hospital. She said, “I don’t have an answer for that.””

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure that the Medical Staff Office had an accountable and reliable processes to initiate the process and investigate, analyze, and address concerns regarding an impaired Doctor (Doctor #9). This failure caused the Human Resources Department to make decisions, that could have affected patient care, without the review of the Medical Executive Committee or Governing Body. Findings: The “York Hospital Medical Staff Bylaws and Regulations”, last revised in 05/2019 states, in part, “A. The provision of quality patient care is of primary importance to York Hospital, its Board of Trustees and its Medical Staff. It is recognized that practitioners who are suffering from physical or mental impairments may compromise the quality of patient care. York Hospital has developed this procedure to help identify, monitor and address practitioners with impairments. It is the policy of York Hospital to encourage disclosure by practitioners of any impairment which might affect the ability to safely practice medicine, to assist such practitioners in obtaining necessary treatment and, when appropriate, to provide reasonable accommodations to allow such practitioners to continue the practice of medicine. B. Impaired practitioner is any practitioner suffering from a physical or mental illness, excessive use or abuse of drugs or alcohol, or deterioration due to the aging process which might impair his or her ability to practice medicine with a reasonable degree of skill and safety. Ad Hoc/Provider Health Committee: C. Appointment: There shall be a minimum of three (3) but no more than five (5) providers on an Ad Hoc/Provider Health Committee, appointed as necessary by the Chair of the Medical Executive Committee when there are reasonable grounds for review. The Medical Executive Committee will determine if there is a reasonable ground to convene. D. Reasonability: The Provider Health Committee shall assist the Medical Executive Committee in the monitoring of the clinical performance of individuals with delineated clinical privileges. The Committee shall act as a resource for any Impaired Practitioner and may recommend treatment, counseling, etc. If any information is brought to the attention of the Provider Health Committee indicating that a practitioner is or may be impaired, the Committee or a member thereof may interview the provider and offer or recommend treatment, further evaluation or modification/restrictions to the practitioner’s practice. The practitioner may also be referred to the Provider Health Program of the Maine Medical Association. The Provider Health Committee shall have no authority to impose any discipline or mandate any action involving the Provider. However, if the practitioner does not accept the Committee’s assistance or recommendations the Committee shall report their findings and recommendations to the President of the Medical Staff. E. Reports to the Provider Health Committee: All members of the Medical Staff and employees of York Hospital are encouraged to consult with the Medical Staff President and/or the Hospital President if there are reasonable grounds to suspect that another member of the Medical Staff is impaired. Members of the Medical Staff are also encouraged to disclose to the Committee, or a member thereof, their own physical or mental conditions which might impair their ability to safely practice medicine. In the absence of a sitting Provider Health Committee the Medical Staff President can be contacted. F. Confidentiality: All reports by third parties and all discussions between a practitioner and the Provider Health Committee or a member thereof shall be kept confidential. The Committee shall report to the Medical Executive Committee, identifying the impaired practitioner anonymously and summarizing the actions recommended by the Committee and the actions taken by the impaired practitioner. These reports shall be maintained in confidence by the Medical Executive Committee in accordance with Maine State Statutes. G. Reportability: Neither the fact that an Impaired practitioner seeks assistance from the Provider Health Committee nor any action undertaken by the practitioner as a result of discussions with the Provider Health Committee shall be reportable to the National Practitioner Data Bank, the Maine Board of Licensure in Medicine, the Maine Board of Osteopathic Licensure or other appropriate licensing board as a disciplinary or adverse clinical privilege action. Likewise, as long as the Impaired practitioner has cooperated with the Provider Health Committee, such matters shall not be reportable by the Provider Health Committee to any other committee or officer of the Medical Staff or York Hospital/ However, the fact that a practitioner seeks assistance or enters into a treatment program shall not preclude an investigation and possible adverse action by other appropriate or Medical Staff committees or officers under the Medical Staff Bylaws. H. Subsequent Action: Report to the President of the Medical Staff or Chief Executive Officer: If a practitioner who is suspected of being impaired has refused to cooperate with the Provider Health Committee or has declined to accept the assistance or recommendations of the Committee, the Committee shall report its findings and its recommendations to the President of the Medical Staff or the Hospital President . The Medical Staff President and/or Hospital President shall meet with the practitioner to discuss the matter. I. Action by Medical Staff President and/or Hospital President: If the practitioner still refuses to accept the recommendations of the Provider Health Committee, the Medical Staff President and/or Hospital President may recommend one or more of the following actions: 1. A requirement that the practitioner undergo treatment as a condition of continued Medical Staff privileges; 2. Restrictions on the practitioner’s clinical privileges; 3. Suspension or termination of the provider’s Medical Staff membership; 4. A request that the practitioner be evaluated by a provider or other appropriate health care professional, selected by the Hospital, who is not a member of the Hospital’s Medical Staff; 5. A requirement that the practitioner submit periodic health status reports from his/her personal provider or health care professional, certifying that the practitioner remains able to safely practice medicine; or 6. No further action. A member of the Medical Staff who has taken a leave of absence, due to impairment, from the Medical Staff either voluntary or involuntary, or who has been suspended from the Medical Staff, must submit a request for reinstatement. The following information will be requested by the Hospital President and/or Credentials Committee: 1. A letter from an involved treatment center which covers the following: a) Description of the impairment; b) Current status of the impairment; c) Description of the treatment, and d) Statement of the long term prognosis. 2. A letter from the impaired staff member’s personal provider covering the four points listed in (1) above and: a) Personal provider’s opinion of the effect of impairment on Staff Member’s professional performance; b) Personal provider’s statement that the impairment has been treated and that no adverse impact is anticipated; and c) Any additional pertinent information. 3. A letter from the impaired Staff Member which covers the following: a) Description of the impairment; b) Provider’s opinion as to whether the impairment is treated and whether professional performance has been affected; and c) Statement that Staff Members will accept periodic medical evaluations at the request of Administration, Medical Staff President, Credentials Committee, Board of Trustees and/or the appropriate department chiefs. The evaluation is to be performed by a provider qualified by education, training and experience to care for an individual with the condition for which the impaired staff member was treated, who has been chosen by or is acceptable to York Hospital. Q. York Hospital may request periodic status reports covering all points in item (2) above. R. York Hospital will have the right to evaluate the impaired Staff Member for a period of time after the Staff Member is reinstated to the Medical Staff. S. If at any point during the process of evaluation, rehabilitation or reinstatement the provider refuses/fails to comply with this procedure he/she may be summarily suspended in accordance with the standards and procedures established in the Bylaws ... .” On 01/09/2025 at 11:02 AM, Doctor #1 stated the following during an interview: - We had an impaired provider but [he/she] is no longer on staff; - This was back in July and [he/she] ended up taking time off; - [He/She] got letters of support and returned to patient care and then didn’t show up for the shift; and - [He/She] was employed by the hospital. On 01/09/2025 at 1:06 PM, nine (9) Medical Staff were chosen and their credentialing files were reviewed with the Medical Staffing Office Coordinator. The following was identified when Doctor #9’s credentialing file was reviewed: - The Director of Quality stated there are no quality files for the medical staff; - The Medical Staffing Office Coordinator stated she had heard there was a concern but did not receive any information about that; - She heard through the grapevine a concern that [Doctor #9] wasn’t able to be located [by staff] in the ED; - She heard that when [Doctor #9] was located there was additional questioning about whether [he/she] was under the influence; - It was determined that [he/she] was not but I don’t know how that was decided; - This occurred between February through May [of 2024]; - She deactivated [him/her] in the database because she received information from Human Resources; and - They stated that it was an ending of [his/her] contract, but is not sure when that happened. On 01/10/2025 at 8:50 AM, the Chief Human Resources Officer, Director of Compliance and Privacy, Medical Staff President (as of 09/2024) and the Chief Executive Officer were interviewed by a surveyor and Physician Consultant surveyor in regard to Doctor #9. On 01/10/2025 at 9:17 AM, the Chief Human Resources Officer stated: - This situation happened in March of 2024; and - There is no question of [his/her] impairment. The timeline for Doctor #9, per the Chief Human Resources Officer, is as follows: - On 03/18/2024, nursing leadership completed a “York Hospital Provider Incident Form” stating that on that day, Doctor #9 could not be located for approximately forty-five (45) minutes during the scheduled shift; - Eventually, [he/she] was located but staff felt [he/she] appeared slightly disheveled and seemed “off”; - Later that same day, the Chief Human Resources Officer, the Chief Administrator and the nurse leader met with Doctor #9; - [He/She] admitted to leaving the unit to “take a break” but will not do that again without notifying staff; - “No further action” was noted; - On 05/09/2024 at 2:07 PM, an email from [the Director of the Department for Doctor #9] was sent to the (former) Chief Medical Officer; - The supervisor stated, in part, that he was notified of Doctor #9 calling out for several shifts in a row due to sickness; - He stated that Doctor #22 was called by Doctor #9. Doctor #21 expressed concerns about [him/her] and getting possible help for drug or alcohol problems; - Doctor #21 remained concerned about Doctor #9’s conduct; - In the email, he also noted that another staff member came forward on 05/01/2024, stating that when they were talking with Doctor #9, the smell alcohol was present; - Doctor #9 worked at the hospital on the following days in May (05/01/2024, 05/16/2024 - 05/18/2024, 05/20/2024, 05/26/2024 - 05/28/2024 and 05/31/2024), for a total of ten (10) shifts; - On 05/29/2024 at 12:42 PM, the (former) Chief Medical Officer sent an email to Chief Human Resources Officer, the Chief Administrator and the Human Resources Director; - He stated that he was made aware that morning that a staff member noticed that Doctor #9 had facial flushing and smelled of alcohol on Sunday [05/26/2024] while working with patients, but was not escalated further; - There were concerns about the clinical decision making for a patient he would bring it forward to the (former) Medical Staff President; - Following that email, there was no documented evidence that the Medical Staff Office was made aware of any concerns for patient care related to the possible impairment of Doctor #9; - Doctor #9 continued to work at the hospital, caring for patients on the following days in June and early July (06/01/2024 - 06/04/2024, 06/07/2024 - 06/11/2024, 06/14/2024, 06/16/2024 - 06/18/2024, 06/21/2024, 06/24/2024, 07/01/2024, 07/07/2024 and 07/09/2024), for a total of eighteen (18) shifts; - On 07/18/2024, the Chief Human Resources Officer called Doctor #9 in regard to what was going on for [him/her]; - In part, it was noted that Doctor #9 was dealing with “bouts of alcohol”, “anxiety”, it was not the job [he/she] signed up for and did not think that [he/she] could do the job anymore; - Following the phone call where Doctor #9 confirmed that [he/she] was unable to care for patients, there was no documented evidence that the Medical Staff Office was made aware; - Doctor #9 was told to take some time off; - On 08/14/2024, Doctor #9 provided a letter from his Doctor stating that [he/she] was safe to return to work without restrictions; - Doctor #9 continued to work at the hospital, caring for patients on the following days in August (08/18/2024 - 08/20/2024 and 08/26/2024 - 08/27/2024), for a total of five (5) shifts; and - The last shift Doctor #9 worked was on 08/27/2024, with no documented evidence of any concerns or documented discussions in his credential file; - There was no documented evidence that the Human Resources Department or the Chief Executive Officer of the hospital relayed any concerns to the Medical Staff Office could not show evidence that the Medical Staff Bylaws rule for a possibly impaired Doctor were followed; and - The Chief Executive Officer stated that he sent in some information to the Maine Board of Medicine but could not recall when that was done but was able to show that the Maine Board of Medicine received the information on 09/09/2024. On 01/10/2025 at 9:43 AM, the Director of Compliance and Privacy confirmed there was no committee that was initiated, as required per the bylaws. On 01/10/2025 at 9:49 AM, the Medical Staff President (as of 09/2024) stated that the [Medical Staff President] needs to be made aware of this type of situation. On 01/10/2025 at 9:59 AM, the Chief Executive Officer stated that [the Director of the Department for Doctor #9] was fully aware. When asked if the Medical Staff President was notified of this situation with Doctor #9, he stated that he doesn’t have anything in his files about speaking to [the Medical Staff President]. When asked if he agreed that the Medical Staff President would need to be made aware of a physician who is impaired, he stated, “You are probably accurate, but I would have to go check the bylaws.” The AdHoc/Provider Health Committee, appointed by the Chair of the Medical Executive Committee, were not aware of any concerns and could therefore, not initiate the proper review. There were also several Doctor’s involved who were aware of Doctor #9’s impairment and did not bring their concerns, as encouraged in the bylaws, to the Medical Staff President and/or the Hospital President. Hospital leadership and Human Resources were aware for approximately one hundred and ten (110) days that Doctor #9 was caring for patients at the hospital during thirty-three (33) shifts knowing the significant concerns regarding [his/her] impairment.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 48232 Based on document reviews and interviews, the hospital failed to ensure: 1) That operating room air distribution systems for the Operating Room (“OR”) suites received preventive maintenance to include but not limited to regular testing, adjusting, and balancing for greater than seven (7) years, for five (5) of five (5) OR’s (OR #1 - 5); failed to ensure preventative maintenance to include but not limited to repairs were scheduled and performed in one (1) of two (2) Computed Tomography (“CT”) areas observed (CT #2) and ensure plumbing fixtures in the kitchen of the Medical/Surgical unit were repaired and maintained in a sanitary condition in one (1) of two (2) observed Medical/Surgical unit kitchens. Findings: 1. Operating Rooms: York Hospital has adopted the Association of Perioperative Registered Nurses’ (“AORN”) standards. AORN’s standard for air flow handling lists the following lists the following suites/parameters: -Minimum Total Air Changes Per Hour: 20 -Minimum total Outdoor Air Changes: 4 -Design Temperature: 68-75 Degrees Fahrenheit -Design Relative Humidity: 20% - 60% -Pressure Relationship to Adjacent Areas: Positive A Testing, Adjusting & Balancing Completion Report for the Air Distribution Systems at York Hospital Operating Rooms was reviewed and revealed that prior to the date of the initiation of this recertification survey (01/07/2025), the last time the York Hospital OR suites preventive maintenance to include but not limited to testing, adjusting, and balancing of the OR suites’ air handling system was on 07/14/2017. On 01/13/2025 at 10:57 AM an in-person interview was conducted with the Executive Director of Operations and Development, during which they confirmed that prior to the date of the initiation of this recertification survey, the OR suites’ air distribution systems had not been calibrated since 2017. The Executive Director of Operations and Development stated that the hospital did not have a regular interval at which this was done, and they indicated that as far as they were aware there wasn’t a standard policy or process for the regular re-calibration of air distribution equipment in the operating room. On 01/14/2025 at 8:55 AM, a telephone interview was conducted with the hospital’s Heating Ventilation and Air Conditioning (“HVAC”) Contractor. The HVAC Contractor stated testing, adjusting, and balancing was important in the operating rooms because they want to confirm they are meeting the air changes required per hour, to make sure the air is moving, and that there are no contaminants from out in the hallway are being pulled into the OR suites. The HVAC Contractor stated that if air from other areas entered the OR suites, it would be an infection risk. The HVAC Contractor stated that the standard for the industry was to have preventative maintenance to include but not limited to testing, adjusting, and balancing done yearly. The HVAC Contractor confirmed that the last time they had performed preventative maintenance to include but not limited to testing, adjusting, and balancing at York Hospital was in 2017. On 01/09/2025 at 11:03 AM, the Executive Director of Operations and Development confirmed there is no written policy or procedure that compelled staff to submit work orders for facility maintenance issues once they were discovered. 2. Computed Tomography Areas Observation of the patient care area, CT #2, 01/07/2025 at 1:04 PM revealed the following: - A cabinet door underneath the sink had an exposed screw sticking out in a way that could potentially cause injury; - The handles on two (2) of the cabinets in the CT area were broken; - The flooring in CT #2 was damaged underneath one of the hand sanitizer dispensers (due to the dispenser drippings?); and - Broken ceiling tiles in the staff/control area of CT #2. The Director of Imaging was present during observation and was made aware of these issues at the time of observation. On 01/09/2025 at 11:03 AM, the Executive Director of Operations and Development confirmed there is no written policy or procedure that compelled staff to submit work orders for facility maintenance issues once they were discovered. 3. Medical/Surgical Unit On 01/07/2025 11:59 AM, the survey team observed a water line next to the sink in the medical/surgical kitchen on the unit Biewind was folded over itself and held together with clear tape. The clear tape was soiled with an unidentified red/pink substance. The Executive Director of Operations and Development was present for the observations confirmed this was a water line.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 48232 Based on document reviews, interviews, and observations, the hospital failed to ensure expired supplies were removed from circulation at the York Hospital Emergency Care in Wells, and in the Sterile Processing Department. Findings: York Hospital’s policy titled, “General Stockroom Inventory and Storage and Security,” last revised 03/2024 states in part, “ ... Outdated/expired items must be removed from supply stock and set aside for proper disposal, donation, or returned to the manufacturer if possible ... .” On 01/08/2025 at 1:49 PM, observations were conducted in the Sterile Processing Department. The following was identified: - It was observed that three (3) containers of Povidone Iodine Swabsticks were present in the hanger that had expired in 11/2024; and - A supply storage hanger on one of the racks that stated “Out Dates Checked 01/11/2025”. On 01/08/2025 at 1:49 PM, the Central Sterile Coordinator confirmed these supplies were expired. On 01/13/2025 from 10:33 AM - 12:04 PM, observations were conducted at York Hospital Emergency Care in Wells. The following was indentified: - One (1) pair of surgical gloves on the adult code cart expired on 11/2024; - Three (3) 22 gauge syringes were expired; and - One (1) 18 gauge syringe in exam room #3 were expired. The Nurse Manager present for these observations was made aware of the expired items at the time of observation.”

“VENTILATION, LIGHT, TEMPERATURE CONTROLS CFR(s): 482.41(c)(4) There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas. This Standard is not met as evidenced by: 48232 Based on document reviews, interviews, and observations, the hospital failed to ensure humidity levels were monitored and recorded in Operating Room (“OR”) #3 for the entire months of February, March, April, August, September, October, and November of 2024, and portions of the months of May, July, and December of 2024. Findings: The York Hospital’s policy titled, “Temperature and Humidity of Surgical Services,” last revised 10/2022 states in part: “...The temperature of the Operating Rooms should be from 68F - 75F with humidity from 20% to 60%. These temperatures must be intentionally adjusted for a limited time based on individual case needs ...On all days that the Operating rooms are open temperature and humidity will be logged before the first case begins...Temperature and Humidity will be logged by the housekeeper daily. On days that housekeeping is not present, temperature and humidity will be logged by the Clinical Coordinator or Charge Nurse...At any time the relative humidity of any Operating room is outside the above range Maintenance on call should be contacted and the call documented on the temperature and humidity log...” On 01/09/2025, OR Temperature and Humidity Logs for Operating Rooms 1, 2, 3, 4, & 5 were reviewed which revealed the following: - February 2024: No humidity data was recorded for February 2024 for OR #3 - March 2024: No humidity data was recorded for all of March 2024 for OR #3 - April 2024: No humidity data was recorded for all of April 2024 for OR #3 - May 2024: No humidity data was recorded for May 1, 2, 6, 7, 8, 9, 13, 14, 15, 16, 20, 21, 22, 23, 28, 29, 30 for OR #3. -July 2024: No Humidity data was recorded for July 1, 2, 3, 8, 9, 10, 11, 15, 16, 17, 18, 22, 23, 24, 25, 29, 30, 31 for OR #3 - August 2024: No humidity data was recorded for all of August 2024 for OR #3 - September 2024: No humidity data was recorded for all of September 2024 for OR #3 - October 2024: No humidity data was recorded for all of October 2024 for OR #3 - November 2024: No humidity data was recorded for all of November 2024 for OR #3 - December 2024: No Humidity data was recorded for December 2, 3, 4, 5, 9, 10, 11, 12, 16, 17, 18, 19, 23, 24, 26, 30, 31 On the dates where no humidity data was recorded, it was observed that the “Humidity” spaces on the above dates were lined through on the logs, indicating the measurements were not missed. On 01/09/2025 at 12:49 PM, an interview was conducted with the Director of Surgical Services and stated the following: - It is important to monitor humidity in the operating room for sterility purposes and for equipment to function properly; - The equipment has a humidity requirement for it to function; and - The humidity levels not being monitored could be an infection risk. On 01/10/2025 at 9:01 AM, an interview was conducted with the Director of Surgical Services and stated the following: - The humidity detection equipment in OR #3 was out of service for the majority of 2024; - It was not reported to me that OR #3 didn’t have a working humidity reader; - We weren’t verifying the humidity logs; and - “Looking back at the logs, it was pretty much the whole year.” On 01/10/2025 at 9:10 AM, The Director of Surgical Services confirmed that staff were drawing a line through the humidity line on the OR Temperature and Humidity Logs for OR #3 for [2024], indicating the item was looked at by staff and there was no action taken. On 01/13/2025 at 11:52 AM, The Director of Corporate Compliance and Privacy communicated the following statement regarding humidity levels in the operating room via email , “... Heat and humidity are intimately intertwined, one affects the other and vice versa ... Humidity that is too low is a fire risk - in an OR you have anesthetic gases, lots of electrical equipment, electro-cautery devices ... between 20% - 60% is generally acceptable ... Humidity that is too high is an infection risk - pathogens thrive in a warm, moist environment...””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48232 Based on observations, interviews, and document reviews, the hospital failed to ensure the following: 1) That the patient food storage freezer was maintained in a sanitary condition for one (1) out of three (3) patient food storage freezers observed (the freezer in the Intensive Care Unit); 2) That opened containers of prepared foods and condiments were labeled with the date in one (1) out of one (1) observed kitchen walk-in refrigerator (the walk-in refrigerator in the main hospital kitchen); and that laboratory supplies were being stored in a sanitary manner in one (1) out of one (1) observed laboratory blood bank (the blood bank located at the York Hospital main campus). Findings: 1. Food Storage The hospital’s policy titled, “Purchasing, Receiving, Storage and Issuing of Food and Supplies,” last revised 05/2024 stated in part, “...Prepared items are clearly covered, labeled [sic.], dated and stored safely to prevent contamination...” On 01/07/2025 at 11:51 AM, during observation of the Intensive Care Unit, the survey team observed dirt, debris and an unidentified red substance on the bottom of the freezer containing patient food. On 01/07/2025 at 11:51 AM, the Medical Surgical and Intensive Care Unit Director was notified of the condition of the freezer and confirmed that the food stored in this freezer was for patients. 2. Labeling Food and Supplies The hospital’s policy titled, “Purchasing, Receiving, Storage and Issuing of Food and Supplies,” last revised 05/2024 states in part, “...Prepared items are clearly covered, labeled [sic.], dated and stored safely to prevent contamination...” During observation of the main hospital kitchen on 01/07/2025 at approximately 2:20 PM the following was observed: - An open container of soup, covered in plastic wrap, that was not dated, the top of the container was labeled with, “Cream of Cauliflower for Wednesday.” -Opened jars of condiments including Caesar Salad Dressing, Thousand Island Dressing, & Buffalo Wing Sauce which were not dated. At the time of the observation, the Dining and Nutrition Staff Member confirmed that the container of soup, salad dressings, and buffalo wing sauce were not dated. 3. Blood Bank Storage The hospital’s policy titled, “Medication, Specimen, and Reagent Storage,” last revised 05/2023 was reviewed and did not reveal any information related to not storing reagents directly on the ground. On 01/08/2025 at 8:25 AM, during observation of the York Hospital Blood Bank, it was observed that a box labeled, “D-10 Hemoglobin A1C Program,” was being directly stored on the floor of the Blood Bank. This product was confirmed by the Lab Administrative Director to be a reagent for labs. At the time of the observation, the Lab Administrative Director confirmed that the reagent should not be stored on the ground.”

“ABX STEWARDSHIP LEADERSHIP COMMUNICATION CFR(s): This Standard is not met as evidenced by: 48232 Based on document reviews and interviews, the hospital failed to ensure the Antibiotic Stewardship Program was participating in Quality Assessment and Performance Improvement (“QAPI”). Findings: On 01/09/2025 at 9:57 AM, the Antibiotic Stewardship Program Leader stated their last quality presentation was in August of 2022. The Antibiotic Stewardship Program Leader stated they had not reported to Quality since 2022, and stated they had asked to, but Quality hadn’t prioritized it. They stated no quality data had been reported to Quality from Antibiotic Stewardship for 2 years. On 01/09/2025 at 10:15 AM, the Director of Quality and Risk Management confirmed the Antibiotic Stewardship Program hadn’t reported any data to Quality since 2022, that they were not integrated with QAPI as of 01/09/2025, the date of the interview, and confirmed the last time the Antibiotic Stewardship Program participated in QAPI was in 2022.”

“Building Rehabilitation CFR(s): NFPA 101 Building Rehabilitation Repair, Renovation, Modification, or Reconstruction Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following: * Requirements of Chapter 18 and 19 * Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6 18.1.1.4.3, 19.1.1.4.3, 43.1.2.1 Change of Use or Change of Occupancy Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2 18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7) Additions Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8. 18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8) This Standard is not met as evidenced by: 47175 Based on observation and interview, the facility failed to ensure that the construction areas were safeguarded in accordance with NFPA241 2009 edition, and NFPA 101, Life Safety Code, section 43.8 as inspected in the facility located within the facility. This deficient practice could affect the patients/residents, visitors, and members of facility staff in this location(s). Deficient practices have the potential of allowing the passage of smoke and/or fire from the construction area(s) into adjacent areas. Findings Include: Observation(s) and lnterview(s) during a Healthcare facility tour with the Carpenter on 01/07/2025 between the hours of 10:00 am and 5:30pm found the following: 1. Multiple penetrations from the Cath Lab renovation area were observed above the double doors to the cath lab corridor non-construction hospital side, as well as from the room to the right of the double doors to the cath lab corridor hospital side. Walls were penetrated by piping, wiring, and open penetraitions that were not protected by a firestop system in accordance with NFPA 101, Life Safety Code, 2012 edition, section 8.3.5 Penetrations and has the potential of allowing the passage of smoke and/or fire into adjacent areas. These findings were verified by the Carpenter at the time of the observation and at the exit conference on 01/07/2025.”

“Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This Standard is not met as evidenced by: 47175 Based on observation and interview, the health care facility failed to ensure that Building construction type and stories meets NFPA 101 2012 edition Table 19.1.6.1 requirements for building type II (222) construction, and maintaining the fire protection rating of structural components. Finding: On 1/7/2025, between 10:00 AM and 5:30 PM, a surveyor, with the Carpenter present, observed the following: 1. Fire proofing on structural beams missing or has been damaged in the Cath lab construction area. The surveyor confirmed this finding with the Carpenter at the time of the observation. 51959 Based on observation and interview, the health care facility failed to ensure that Building construction type and stories meets NFPA 101 2012 edition Table 19.1.6.1 requirements for building type II (222) construction, and maintaining the fire protection rating of structural components. Finding: On January 7, 2025, between 10:00 AM and 5:30 PM, a surveyor, with the Facilities Coordinator present, observed the following: 1. Fire proofing on structural beam is missing or has been removed at the top of the stairwell that provides access to the level 2 staff lounge. 2. Two data cables penetrating 2hr fire barrier above ceiling located on level 2 where smoke compartments 2, 3, 4, 5 intersect, without fire stopping. The surveyor confirmed this finding with the Facilities Coordinator at the time of the observation.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 45039 Based on observation and interview, the hospital failed to maintain the aisles, passageways, corridors, exit discharges, exit locations, and access free of all obstructions to full use in case of emergency per NFPA 101, Life Safety Code, 2012 Edition, Sections 19.2.1, and 7.1.10.1 Findings: On 01.07.2025, between 10:00 AM and 5:30 PM, this surveyor, observed the following finding with the HVAC tech present. 1. 2 blood pressure machines were plugged into a corridor outlet and stored in the egress corridor across from room 202 in the Biewind Wing 2. A computer was plugged into a corridor outlet and stored in the egress corridor across from room 209 in the Biewind Wing 3. 3 blood pressure machines were plugged into a corridor outlet and stored in the egress corridor across from room 258 in the Strater Wing 4. A blood pressure machine was plugged into a corridor outlet and stored in the egress corridor across from room 260 in the Strater Wing 5. Operating room beds, sterile supplies and portable machines were stored in the ground level egress corridor. The surveyor confirmed these findings with the HVAC tech at the time of the observation and review. 47175 Based on observation and interview, the healthcare facility failed to ensure that Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with NFPA 101 2012 edition Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18,2.1, 19.2.1, 7.1.10.1 Finding: On 1/7/2025, 10:00 AM and 5:30 PM, a surveyor, with the Carpenter present, observed the following: 1. Cabinets and wheeled storage containers were found stored in the corridor in the x-ray wing. 2. Cabinets and wheeled storage containers were found stored in the corridor outside of the OR rooms. 3. Cabinets and wheeled storage containers were found stored in the corridor in the ICU wing. 4. A makeshift waiting area was found set up in front of marked exit doors leaving the MRI area blocking the door. The surveyor confirmed this finding with The carpenter at he time of the observation.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 38667 Based on observation, the facility failed to ensure that doors in an exit passageway, starirway enclosure, or horizontal exit, smoke barrier, or hazardous area enclousre are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automaticaly closes all such doors throughout the smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and automatic sprinkler system, if installed; and loss of poer per the requirements of NFPA 101 2012 edition Findings: On 01/07/2025 between hours of 10:00 am and 5:30 pm. this surveyor accompanied with the Carpenter did observe the following: 1. 90 minute rated Door 1039 to the ICU waiting room on magnetic hold open was not self-closing or positive latching. 2. Rated door labeled as FD30 on magnetic hold open on the first floor was not positive latching The surveyor confirmed this finding with the Carpenter at the time of the observation 47175 Based on observation and interview, the facility failed to enrure that doors in an exit passageway, stariway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.1 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of required manual fire alarm system, and local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system: and automatic sprinkler system, if installed; and loss of power per the requirements of NFPA 101 2012 edition. Findings On 01/07/2025 between hours of 10:0am and 5:30 pm. this surveyor accompanied with the Carpenter did observe the following: 1. Door in the pharmacy area found wedged open with a piece of wood. 2. Door 1042 is a storage room door that has had the self-closing device removed. 3. Tray return door in the kitchen area was blocked from closing by carts. 4. Cashier/serving area in kitchen was fixed open with door wedge. 5. The back kitchen exit door was tied open with a rope tied to a bread rack. The surveyor confirmed this finding with the Carpenter at the time of the observation.”

“Aisle, Corridor, or Ramp Width CFR(s): NFPA 101 Aisle, Corridor or Ramp Width 2012 EXISTING The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5. 19.2.3.4, 19.2.3.5 This Standard is not met as evidenced by: 38667 Based on observation and interview, the Heatlhcare facility failed to maintain exit corridor width per NFPA 101, Life Safety Code, 2012 Edition, Section 19.2.3.4 Finding: On 01/07/2025, between 10:00 AM and 5:30 PM, a surveyor, with the Carpenter present, observed the following: 1. The Corridor to MRI zone 2 outside door 1079 imaging staff area shifts from 8’ wide down to 6’4” wide and then again within 6 feet as the corridor turns it is reduced down to 5’10’ wide The surveyor confirmed this finding with the Carepenter at the time of the observation”

“Suite Separation, Hazardous Content, and Subd CFR(s): NFPA 101 Suite Separation, Hazardous Content, and Subdivision All suites are separated from the remainder of the building (including from other suites) by construction meeting the separation provisions for corridor construction (18.3.6.2-18.3.6.5 or 19.3.6.2-19.3.6.5). Existing approved barriers shall be allowed to continue to be used provided they limit the transfer of smoke. Intervening rooms have no hazardous areas and hazardous areas within suites comply with 18/19.2.5.7.1.3. Subdivision of suites shall be by noncombustible or limited-combustible construction. 18.2.5.7.1.2 through 18.2.5.7.1.4, 19.2.5.7.1.2, 19.2.5.7.1.3, 19.2.5.7.1.4 This Standard is not met as evidenced by: 35163 Based on record review and interview, the hospital failed to verify suites are separated from the remainder of the building (including from other suites) by construction meeting the separaton provisions for corridor contruction per NFPA 101, Life Safey Code, 2012 Edittion, Sections 19.3.6.2-19.3.6.5, 19.2.5.7.1.2, 19.2.5.7.1.3, 19.2.5.7.1.4 Findings: On 01.07.2025, between 10:00 AM and 5:30 PM, this surveyor, observed the following finding with the director and facilities coordinator persent. 1. Upon interview the facility stated they have suites located in the building, but was unable to provide documentation to indicate type or or locations of suites. The life safety drawings that were provided did not show any suite designations and the facility stated that updated drawings were in process but were not available at the time of the survey. These finding were verified by the facility executive director and facilities coordinator at the time of document review on 01-07-25.”

“Sleeping Suites CFR(s): NFPA 101 Sleeping Suites Occupants shall have exit access to a corridor or direct access to a horizontal exit. Where greater than or equal to 2 exits are required, one exit access door may be to a stairway, passageway or to the exterior. Suites shall be provided with constant staff supervision. Staff shall have direct visual supervision of patient sleeping rooms, from a constantly attended location or the room shall be provided with an automatic smoke detection system. Suites more than 1,000 square feet shall have 2 or more remote exits. One means of egress from the suite shall be to a corridor and one may be into an adjacent suite separated in accordance with corridor requirements. Suites shall not exceed the following size limitations: * 5,000 square feet if the suite is not fully smoke detected or fully sprinklered * 7,500 square feet if the suite is either fully smoke detected or fully sprinklered * 10,000 square feet if the suite is both fully smoke detected and fully sprinklered and the sleeping rooms have direct supervision from a constantly attended location Travel distance between any point in a suite to exit access shall not exceed 100 feet and distance to an exit shall not exceed 150 feet (200 feet if building is fully sprinklered). 18.2.5.7.2, 19.2.5.7.2 This Standard is not met as evidenced by: 35163 Based on record review and interview, the hospital failed to verify the suite requirements per NFPA 101, Life Safety Code, 2012 Edition, Section 19.2.5.7.2 were met. Findings: On 01.07.2025, between 10:00 AM and 5:30 PM, this surveyor, observed the following finding with the director and facilities coordinator present. 1. Upon interview the facility stated they have suites located in the building, but was unable to provide documentation to indicate type or locations of suites. The life safety drawings that were provided did not show any suite designations and the facility stated that updated drawings were in process but were not available at time of survey. These findings were verified by the facility executive director and facilities coordinator at the time of document review on 01-07-25”

“Non-Sleeping Suites CFR(s): NFPA 101 Non-Sleeping Suites Occupants shall have exit access to a corridor or direct access to a horizontal exit. Where greater than or equal to 2 exits are required, one exit access door may be to a stairway, passageway or to the exterior. Suites more than 2,500 square feet shall have 2 or more remote exits. One means of egress from the suite shall be to a corridor and one may be into an adjacent suite separated in accordance with corridor requirements. Suites shall not exceed 10,000 square feet. Travel distance between any point in a suite to exit access shall not exceed 100 feet and distance to an exit shall not exceed 150 feet (200 feet if building is fully sprinklered). 18.2.5.7.3, 19.2.5.7.3 This Standard is not met as evidenced by: 35163 Based on record review and interview, the hospital failed to verify the requirements for non sleeping suites per NFPA 101, Life Safety Code, 2012 Edition, Section 19.2.5.7.3 were met. Findings: On 01.07.2025, between 10:99 AM and 5:30 PM, this surveyor, observed the following finding with the director and facilities coordinator present. 1. Upon interview the facility stated they have suites located in the building, but was unable to provide documentation to indicate type or locations of suites. The life safety drawings that were provided did not show any suite designations and the facility stated that updated drawings were in process but were not available at the time of the survey. These findings were verified by the facility executive director and facilities coordinator at the time of the document review on 01-07-25”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 45039 Based on observations and interview with the facility failed to meet the requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition for exit and directional signs that are displayed in accordance with 7.10, 19.2.10.1, 19.2.10.2,19.2.10.3, and 19.2.10.4. Findings: On 01.07.2025, between 10:00 AM and 5:30 PM, this surveyor observed the following finding with the HVAC tech present. 1. The area of CT and Cath Lab needs to exit signage with directional signs displaying the proper egress out of the area. The current signs are not lit and not adequate exit signage. 2. The Surgical entrance the current sign is blacked out. This deficient practice could affect the occupants, visitors and staff while trying to exit the building under reduced visibility of the exit areas. The surveyor confirmed these findings with the HVAC tech at the time of the observation and review.”

“Vertical Openings - Enclosure CFR(s): NFPA 101 Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box. This Standard is not met as evidenced by: 51959 Based on observations and interview with the Facilities Coordinator the facility failed to meet the requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition for vertical openings to include stariwells, shafts, in accordance with 19.3.1.1 through 19.3.1.6 Findings include: Observations and Interview, found penetrations into stairwells and not maintaining a 2-hr fire resistive rating during a facility tour on Januay 7, 2025 between 10:00 AM and 5:30 PM with the Facilities Coordinator: 1. Two penetrations (conduit and wiring) into the stairwell above door #2254 2. Sprinkler pipe penetration into the 2-hr rated stairwell located above door #2230 3. Sprinkler pipe penetration into the 2-hr rated stairwell located across the corridor from the elevators 4. Sprinkler pipe penetration into the 2-hr rated stairwell located by door #2327 5. Grouting within the 2-hour wall is crumbling deteriorating located on level 2 elevator shaft. This deficient practice could affect the occupants, visitors and staff while trying to exit the building and utilizing the stariwell that is not have 1-hour fire resistive rating. These finding were verified by the Administrator, and EVS Manager and this Surveyor at the times of observation, interview, and document review on January 07, 2025 between 10:00 AM and 5:30 Based on observations and interview, the facility failed to meet the requirements of the National Fire Protrection Association (NFPA) 101, Life Safety Code, 2012 edition for vertical openings to include stairwells and shafts in accordance with 19.3.1.1 through 19.3.1.6. Findings: On 01.07.2025, between 10:00 AM and 5:30 PM, this surveyor observed the following finding with the HVAC tech present. 1. 2’” Penetration into 2-hour fire wall at the ground level stairwell outside the elevators. 2. Penetrations into 2-hour fire wall at the ground level stairwell around the Special Procedure Passageway. The surveyor confirmed this finding with the HVAC techat thge time of the observation and review.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 38667 Based on observation and interview, the facility failed to ensure that hazardous areas were safeguarded in accordance with NFPA 101, Life Safety Code, section 19.3.2.1 and 19.3.2.1.3 in hazardous areas inspected in the facility located within the facility. This deficient practice could affect the patients/residents, visitors, and members of facility staff in this location(s). Deficient practices have the potential of allowing the passage of smoke and/or fire from the hazardous area(s) into adjacent areas. Findings Include: Observation(s) and lnterview(s) during a Healthcare facility tour with the Carpenter on 01/07/2025 between the hours of 10:00 am and 5:30 pm found the following: 1.The Purchasing Department had many various locations where the spray fireproofing on the ceiling area and structural steel did not have an intact fire barrier having a 1-hour fire resistance rating in accordance with NFPA 101, Life Safety Code, 2012 edition, section 19.3.2 Protection from Hazards. 2.The Purchasing Department had wire penetrations in 1 hour rated wall above door 1- 109 that were not protected with an intact fire barrier having a 1-hour fire resistance rating in accordance with NFPA 101, Life Safety Code, 2012 edition, section 19.3.2 -Protection from Hazards. 3.The Purchasing Department had pipe penetrations in 1 hour rated wall above door 1- 108 8 that were not protected with an intact fire barrier having a 1-hour fire resistance rating in accordance with NFPA 101, Life Safety Code, 2012 edition, section 19.3.2 -Protection from Hazards. 4.The Purchasing Department above the gate to the pharmacy storage area had a sprinkler pipe penetration that was not protected with an intact fire barrier having a 1-hour fire resistance rating in accordance with NFPA 101, Life Safety Code, 2012 edition, section 19.3.2 -Protection from Hazards. 5.Open Conduits within electrical room 1129 were observed penetrating to the floor above that was not protected with an intact fire barrier having a 1-hour fire resistance rating in accordance with NFPA 101, Life Safety Code, 2012 edition, section 19.3.2 -Protection from Hazards. 6.Open penetrations around electrical conduit was observed within the mechanical room on floor 1 behind the Dristeem Humidifier unit labeled as #13 that was not protected with an intact fire barrier having a 1-hour fire resistance rating in accordance with NFPA 101, Life Safety Code, 2012 edition, section 19.3.2 -Protection from Hazards. 7.LB Conduit elbow boxes at door 1061 mechanical room penetrations were observed as not protected with an intact fire barrier having a1-hour fire resistance rating in accordance with NFPA 101, Life Safety Code, 2012 edition, section 19.3.2 -Protection from Hazards. 8.Electrical Conduit within 1 hour rated wall in the telecommunication room above door 1060 was observed as not protected with an intact fire barrier having a 1-hour fire resistance rating in accordance with NFPA 101, Life Safety Code, 2012 edition, section 19.3.2 -Protection from Hazards. 9.Penetrations were observed at elevator machine room at doors 1225 and 1226 as not protected with an intact fire barrier having a 1-hour fire resistance rating in accordance with NFPA 101, Life Safety Code, 2012 edition, section 19.3.2 -Protection from Hazards. 10. Ceiling penetrations in multiple areas within the boiler room located below what was thought to be the medical records area did not have an intact fire barrier having a 1-hour fire resistance rating in accordance with NFPA 101, Life Safety Code, 2012 edition, section 19.3.2-Protection from Hazards. 11.There was no fire resistive barrier between the emergency department and the garage storage area and emergency ambulance unloading area at double sliding doors 1017. It was observed that the garage doors were closed and an emergency vehicle was unloading a patient within the hazardous area during the survey. 12.Elevator machine room door 1226 was not self closing or positive latching. 13.Elevator machine room door 1225 was not self closing or positive latching. Walls were penetrated by piping, wiring, and open penetrations that were not protected by a firestopping system in accordance with NFPA 101, Life Safety Code, 2012 edition, section 8.3.5 Penetrations and has the potential of allowing the passage of smoke and/or fire into adjacent areas. These findings were verified by the Carpenter at the time of the observation and at the exit conference on 01/07/2025. Based on observation and interview, the hospital failed to maintain hazardous areas. per NFPA 101, Life Safety Code, 2012 Edition, Sections 19.3.2.1.3. Findings: On 01.07.2025, between 10:00 AM and 5:30 PM, this surveyor observed the following finding with the HVAC tech present. 1.Storage room next to Data Room 5 on the Biewind Wing does not positive latch. 2.Shower across from Room 213 on the Biewind Wing has been converted to storage. The room is filled with medical equipment that does not allow the door to self-close and latch. 3.Closet in the Education area of the Biewind Wing has magnets to close door. The doors do not positive latch. 4.Patient room 2 in Strater Wing has been converted to a storage room. The door is required to self-close and positive latch. 5.Education Room 223 on the Strater Wing has been converted to a storage room. The door is required to self-close and positive latch. 6.Manifold room on ground level for medical gas does not self-close and positive latch. 7.Electrical/Boiler room on ground level does not self-close and positive latch. When door is released the air pressure from the hallway does not allow door to close and latch. The surveyor confirmed these findings with the HVAC tech at the time of the observation and review. Based on observation and interview, the facility failed to ensure that hazardous areas are protected per the requirements of NFPA 101 2012 edition by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4.3.5. Doors shall be self-closing or automatic-closing and permitted to have non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Findings: On 01/07/2025 between hours of 10:00 am and 5:30 pm. this surveyor accompanied with the Carpenter did observe the following: 1. Temporary storage area set up for the mobile Cath lab was not equipped with a self-closing door to protect from the corridor providing exit access. The surveyor confirmed this finding with the Maintenance Director and the Administrator at the time of the observation. Based on observation, the facility failed to ensure that hazardous areas are protected per the requirements of NFPA 101 2012 edition by a fire barrier having 1-hour fire resistance rating (with 3/4-hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Findings: On January 7, 2025, between hours of 10:00 am and 5:30 pm. this surveyor accompanied with facilities coordinator, did observe the following: 1. Penetrations in the 1-hour rated fire wall between general receiving and the pharmacy. 2. Penetrations in the 1-hour rated wall between the large storage room into the corridor across from the kitchen. 3. Penetrations (pipes cut off and left in place) in the rated floor ceiling assembly in storage room directly in front of the piping tunnel. 4. Penetration in the 1- hour rated wall between the storage room and into the corridor across from the sleep room. 5. Penetration in the 1-hour rated will between the boiler room and the electrical room. The surveyor confirmed this finding with the facilities coordinator at the time of the observation”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 38667 Based on observation and interview, the Healthcare facility failed to maintain the proper shutoff mechanism for the Therapy Cooking stove per NFPA 101, Life Safety Code, 2012 Edition, Sections 19.3.2.5 and NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition, section 11.6 and 11.72. This deficient practice could affect the resident, visitors and staff. Findings: Based on interview and observation on 01-07-2026 between hours of 10:00 am and 5:30 pm. this surveyor accompanied with the Carpenter did observe the following: 1. The Grease exhaust hood and grease removal devices, appurtenances and equipment in th location of the carbroiler was found to be heavily contaminated with an excess of grease or oily sludge. 2. The grease exhuast hood and grease removal devices and appurtenances for the griddle was found to be contaminated with an excess of grease or oily sludge. This was observed at the time by this surveyor along with carpenter.”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 50053 Based on observation, the Healthcare facility failed to install their fire alarm system in accordance with NFPA 72, 2010 edition and failed to meet the requirements of 18.5.4. Finding: Based on observations on 01-07-2025 10:00 AM and 5:30 PM, a surveyor observed the following: 1. Two different model fire alarm notification devices within 10’ of each other found in the in the corridor of smoke compartment #2 on level 1 outside of clean utility leading to ICU.”

“Fire Alarm System - Initiation CFR(s): NFPA 101 Fire Alarm System - Initiation Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse’s stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200’ travel distance is not exceeded. 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5 This Standard is not met as evidenced by: 38667 Based on observation and interview, the Healthcare facility, the facility failed to maintain accessibility for the manual fire alarm pull stations throughout the facility per NFPA 101, 2012 edition, sections 19.3.4.2.1 and 19.3.4.2.2, 9.6.2.3 and NFPA 72 2010 edition, Section 17.14 Finding: Based on observation and interview on 01-07-2025 10:00 AM and 5:30 PM, a surveyor, with the Carpenter, observed the following: 1. The fire alarm pull station located at the exit to the emergency room was observed to be obstructed by wheelchairs. The surveyor confirmed this finding with the Carpenter at the time of the observation.”

“Fire Alarm System - Out of Service CFR(s): NFPA 101 Fire Alarm - Out of Service Where required fire alarm system is out of services for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. 9.6.1.6 This Standard is not met as evidenced by: 16732 The hospital failed to provide policy for Fire Alarm Out Of Service more than 4 hours in a 24 hour period in accordance with NFPA 101 Section 9.6.1.6 Findings: Based on record review and interview on 01-07-2025 between hours of 10:00 AM and 5:30 PM, a surveyor observed the following: 1. There is no documentation that the facility has Fire Alarm Out of Service Policy if the fire alarm system is out of services for more than 4 hours in a 24-hour period. This was confirmed in interview with the Executive Director”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 38667 Based on observation and interview, during a Healthcare facility tour, the facility failed to ensure that hazardous areas were safeguarded in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 edition Life Safety Code, section 8.1.1.(1) in two hazardous area of the smoke compartments inspected in the facility that sprinklers are to be installed throughout the premises. This deficient practice could affect the patients/residents, visitors, and members of facility staff in this location(s). Deficient practices have the potential of allowing the passage of smoke and/or fire from the hazardous area(s) into adjacent areas. This deficient practice could affect the patients/residents, visitors, and members of facility staff in this location(s). Findings: Observation(s) and lnterview(s) during a facility tour with the Carpenter on 01/07/2025 from 10:00 AM to 5:30 PM identified: No sprinkler coverage was observed within the elevator hydraulic machine room at door1185 Based on observation and interview, during a Healthcare facility tour, the facility failed to ensure that hazardous areas were safeguarded in accordance with NFPA 13, Standard for Installation of Sprinkler Systems, 2010 edition, section 8.9.5.3.2 in 2 hazardous areas of 5 smoke compartments inspected in the facility. This deficient practice could affect the patients/residents, visitors, and members of facility staff in this location(s). Deficient practices have the potential of allowing the passage of smoke and/or fire from the hazardous area(s) into adjacent areas. This deficient practice could affect the patients/residents, visitors, and members of facility staff in this location(s). Based on interview and observation on January 7, 2025 between hours of 10:00 am and 5:30 pm. this surveyor accompanied with the Facilities Coordinator did observe the following: a. No sprinkler coverage was observed under the garage door in level 1 soiled linen room - access to mobile MRI. b Escutcheon plate not seated in Pharmacy. These findings were confirmed with the Facilities Coordinator”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 38667 Based on observation, the healthcare facility failed to ensure that Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA25 2011 edition, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems sections Chapter 5, section 5.2.1.1.1 On 01/07/2025, between 10:00 AM and 5:30 PM, surveyor, with the Carpenter observed the following: 1. Sprinkler heads found loaded with excessive amounts of dust throughout level 1, areas include: a. Corridor outside of housekeeping storage room b. Various locations within the pharmacy c. Within the vestibule between the two sets of double sliding doors to ambulance bay at door 1-017 d. Various corridor locations 2. Storage found located closer than 18” to a sprinkler head a. Within the Temporary Cath Lab storage room b. Within the storage closet with bi-fold doors in the speech therapy room 3. Items temporarily affixed to a sprinkler pipe Within the Gath Lab construction area in various locations The surveyor confirmed these findings with the Carpenter at the time of the observation. Based on observation and interview, the healthcare facility failed to ensure that Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25 2011 edition, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems sections Chapter 5, section 5.2.1.1.1. Findings: On 01/07/2025, between 10:00 AM and 5:30 PM, surveyor, with the Carpenter observed the following: 1. Sprinkler heads found loaded with excessive amounts of dust throughout level 1, areas include: a. Housekeeping floor 1 MRI room b. Kitchen multiple locations c. Operating rooms 3 and 4 d. Various corridor locations 2. Temporary lighting fixtures in the new construction Cath lab area was found hanging from and tied to sprinkler piping. 3. Escutcheon ring was found missing on a sprinkler head in the OR dirty equipment room. The surveyor confirmed these findings with the Carpenter at the time of the observation. Based on observation and interview, the healthcare facility failed to ensure that Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25 2011 edition, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems sections Chapter 5, section 5.2.1.1.1. Findings: On January 7, 2025, between 10:00 AM and 5:30 PM, surveyor, with the Facilities Coordinator observed the following: 1. Items permanently affixed to a sprinkler pipe: Within the large boiler room. 2. Sprinkler Pipe is covered by short pieces of CPVC schedule 40 pipe: a. Level 1 window washing heads - heading toward cafeteria from main hospital b. Level 2 window washing heads - heading into smoke compartment 4 from smoke compartment 3. 3. Blaze master sprinkler piping being used above the ceiling in smoke compartment 4 for sprinkler piping. 4. Conduit and wires hung from sprinkler pipe located above the ceiling between the elevators and where the three wings converge. The surveyor confirmed these findings with the Facilities Coordinator at the time of the observation. Based on observation, the facility failed to ensure that Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA25 2011 edition, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems sections Chapter 5, section 5.2.1.2. Findings: On 01.07.2025, between 10:00 AM and 5:30 PM, this surveyor observed the following finding with the HVAC tech present. 1. Storage found located closer than 18” to a sprinkler head. Central Sterile Storage has storage stacked 1O” below bottom of the sprinkler deflector. The surveyor confirmed these findings with the HVAC tech at the time of the observation and review.The surveyor confirmed these findings with the HVAC tech at the time of the observation and review.”

“Sprinkler System - Out of Service CFR(s): NFPA 101 Sprinkler System - Out of Service Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service. 18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25) This Standard is not met as evidenced by: 16732 Findings: Based on record review and interview on 01-07-2025 between hours of 10:00 AM and 5:30 PM, a surveyor observed the following: 1. There is no documentation that the facility has Fire Alarm Out of Service Policy if the fire alarm system is out of services for more than 4 days in a 24-hour period. This was confirmed in interview with Executive Director.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 45039 Based on observation, the facility failed to ensure portable fire extinguishers are installed and maintained in accordance with NFPA 101, Life Safety Code, 2012 edition, Sections 4.6.12, 9.7.4.1, and 19.3.5.12.. Also reference NFPA 10, Standard for Portable Fire Extinguishers, 2010 edition, sections 7.2.1.2. Finding: On 01/07/2025, between 10:00 AM and 5:30 PM, this surveyor observed the following finding with the Carpenter present. 1. Fire extinguisher access was found blocked by trash cans in the laboratory area in the room to the right of the main entrance to the lab. The surveyor confirmed this finding with the Carpenter at the time of the observation and review. Based on observation, documentation review, and interview the facility failed to ensure portable fire extinguishers are installed and maintained in accordance with NFPA 101, Life Safety Code, 2012 edition, Sections 4.6.12, 9.7.4.1, and 19.3.5.12.. Also reference NFPA 10, Standard for Portable Fire Extinguishers, 2010 edition, sections 7.2.1.2. Finding: On 01.07.2025, between 10:00 AM and 5:30 PM, this surveyor observed the following finding with the HVAC tech present. 1. The red ABC extinguisher in the PACU rear egress corridor has no monthly inspections annotated on the attached tag for November and December, of 2024. The surveyor confirmed this finding with the HVAC tech at the time of the observation and review. Based on observation and interview, the facility failed to ensure portable fire extinguishers are installed and maintained in accordance with NFPA 101, Life Safety Code, 2012 edition, Sections 4.6.12, 9.7.4.1, and 19.3.5.12.. Also reference NFPA 10, Standard for Portable Fire Extinguishers, 2010 edition, sections 7.2.1.2. Finding: On 01/07/2025, between 10:00 AM and 5:30 PM, this surveyor observed the following finding with the Carpenter present. 1. Fire extinguisher access was found blocked in the OR clean equipment room by storage of wheeled carts. The surveyor confirmed this finding with the Carpenter at the time of the observation and review.”

“Corridors - Construction of Walls CFR(s): NFPA 101 Corridors - Construction of Walls 2012 EXISTING Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. In nonsprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Fixed fire window assemblies in corridor walls are in accordance with Section 8.3, but in sprinklered compartments there are no restrictions in area or fire resistance of glass or frames. If the walls have a fire resistance rating, give the rating _____________ if the walls terminate at the underside of the ceiling, give brief description in REMARKS, describing the ceiling throughout the floor area. 19.3.6.2, 19.3.6.2.7 This Standard is not met as evidenced by: 51959 Findings: On January 7, 2025, between 10:00 AM and 5:30 PM, surveyor with the Facilities Coordinator observed the following: 1. Door number 2265 is a 45-minute rated door and is located in a 2-hour rated wall. This door should have a 90-minute rating. 2. 90-minute Rated door has had decoratively painted - This door is located between the corridor and General Receiving Storage. The surveyor confirmed these findings with Facilities Coordinator at the time of the observation.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 38667 Based on observation and interview, the hospital failed to ensure that doors were protecting corridor openings in accordance with NFPA 101, Life Safety Code, section 19.3.6.3 - Corridor Doors. This deficient practice could affect the residents, visitors, and members of facility staff in this location. Findings: On 01-7-2025, between 10:00 AM and 5:30 PM, this surveyor observed the following finding with the Carpenter present. 1. Patient rooms with 2 leaf doors in the ICU suite do not protect the corridor from the smoke and/or fire due to the undercut at the bottom of the door. This is not in accordance NFPA 101, Life Safety Code, 2012 edition, section 19.3.6.3.1 - doors shall resist the passage of smoke. This failure occurred in all of the patient room doors within the ICU suite. 2. Double doors to the ICU suite at doors 1043 exceed the allowable undercut at the bottom of the door and do not protect the corridor from the smoke and/or fire. This is not in accordance NFPA 101, Life Safety Code, 2012 edition, section 19.3.6.3.1 - doors shall resist the passage of smoke. This failure occurred in all of the patient room doors within the ICU suite. 3. 90 minute rate Door 1020 to ED patient room 7 was found fixed open with door wedge. 4. Rated corridor doors on the first floor 1132 was not positive latching. 5. Rated Door 1-085 to x-ray reading room was found to not fully close or positively latch. The surveyor confirmed these findings with the Carpenter at the time of the observation. 45039 Based on observation and interview, the hospital failed to ensure that doors were protecting corridor openings in accordance with NFPA 101, Life Safety Code, section 19.3.6.3 - Corridor Doors. This deficient practice could affect the residents, visitors, and members of facility staff in this location. Findings: On 01.07.2025, between 10:00 AM and 5:30 PM, this surveyor observed the following finding with the HVAC tech present. 1. Patient rooms with 2 leaf doors in Biewind Wing do not protect the corridor from the smoke and/or fire due to the gaps around the door and the frame. This is not in accordance NFPA 101, Life Safety Code, 2012 edition, section 19.3.6.3.1 - doors shall resist the passage of smoke. This failure occurred in 10 of 24 patients’ doors in the Biewind Wing. 2. Patient rooms with 2 leaf doors in the Strater Wing do not protect the corridor opening from the smoke and/or fire due to the gaps around the door and the frame. This is not in accordance NFPA 101, Life Safety Code, 2012 edition, section 19.3.6.3.1 - doors shall resist the passage of smoke. 3. Housekeeping closet in Strater wing has roller latch installed on door. 4. Clean utility on Strater Wing has roller latch installed on door. 5. Linen room on Strater Wing has roller latch installed on door. The surveyor confirmed these findings with the HVAC tech at the time of the observation and review. 51959 Based on observation and interview, the hospital failed to ensure that door were protecting corridor openings in accordance with NFPA, 101. Life Safety Code, 2012 edition, section 19.3.6.3 - Corridor Doors. Findings: On January 7, 2025, between 10:00 AM and 5:30 PM, this surveyor observed the following finding with the Facilities Coordinator present. 1. Cross Corridor Door, door number 2251 has a gap at the bottom exceeding 3/4” and does not resit the passage of smoke. 2. Cross Corridor Door, door number 2280 has a gap at the bottom exceeding 3/4” and does not resit the passage of smoke. 3. Cross Corridor Door, door number 2211 has a gap at the bottom exceeding 3/4” and does not resit the passage of smoke. 4. Cross Corridor Door, door number 2403 has a gap at the bottom exceeding 3/4”, excessive median door gap, and does not resit the passage of smoke. 5. Cross Corridor Door, door number (not found but heading from door number 1153 toward cafeteria, has a gap at the bottom exceeding 3/4” and does not resist the passage of smoke. 6. Door number 2265 is located in a 2-hour rated wall assemply - this door needs to have a rating of at least 90-minutes and is rated at 45-minutes. 7. Cross Corridor Door is a 90-minute rated fire door and has had decorative painting applied to one side. This surveyor confirmed these findings with the HVAC tech at the time of the observation and review.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 38667 Based on observation and interview with the carpenter on 01/07/2025 between 10:00 am and 5:30 PM the facility failed to meet the requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, sections 8.5 and 19.3.7. When required by Chapter 11 through 43 smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke. Findings include: 1. Ceiling tile penetrations and openings outside of door FD33 on the gift shop, apothecary side within the corridor. These findings were verified by the Carpenter at the times of observation, interview, and document review on 01/07/2025 between 10 am and 5:30 PM. 50053 Based on observation and interview with the Facilities Coordinator on 01/07/2025 between 10:00 am and 5:30 PM the facilities failed to meet the requirements of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, sections 8.5 and 19.3.7. When required by Chapter 11 through 43 smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke. Findings include: 1. Ceiling tile penetrations of 1 1/2” x 1 1/2” in corridor near adult health near elevator. 2. Ceiling tile penetrations of 1 1/2” x 1 1/2” in corridor near stairwell near main elevators. These findings were verified by the Facilities Coordinator at the times of observation, interview, and document review on 01/07/2025 between 10 am and 5:30 PM.”

“Combustible Decorations CFR(s): NFPA 101 Combustible Decorations Combustible decorations shall be prohibited unless one of the following is met: o Flame retardant or treated with approved fire-retardant coating that is listed and labeled for product. o Decorations meet NFPA 701. o Decorations exhibit heat release less than 100 kilowatts in accordance with NFPA 289. o Decorations, such as photographs, paintings and other art are attached to the walls, ceilings and non-fire-rated doors in accordance with 18.7.5.6(4) or 19.7.5.6(4). o The decorations in existing occupancies are in such limited quantities that a hazard of fire development or spread is not present. 19.7.5.6 This Standard is not met as evidenced by: 47175 Based on observation and interview, the health care facility failed to ensure that combustible decorations shall be prohibited unless one of the following is met: Flame retardant or treated with approved fire-retardant coating that is listed and labeled for product. Decorations meet NFPA 701 (2010). Decorations exhibit heat release less than 100 kilowatts in accordance with NFPA 289 (2009). Decorations, such as photographs, paintings and other art are attached to the walls, ceilings and non-fire-rated doors in accordance with 18.7.5.6(4) or 19.7.5.6(4). The decorations in existing occupancies are in such limited quantities that a hazard of fire development or spread is not present. 19.7.5.6. Finding: On 1/7/2025, between 10:00 AM and 5:30 PM, a surveyor, with the Carpenter present, observed the following: 1. A fire rated door leading into the pharmacy had a decorative wreath hung and no evidence could be provided to show that it had been sprayed with a fire-retardant coating, or that it met the requirements of NFPA 701 (2010) or NFPA289 (2009). The surveyor confirmed this finding with the Carpenter at the time of the observation.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 50053 Based on observation and interview, the Health Care Facility failed to inspect and maintain rated fire door assemblies in accordance with NFPA 80, Standard for Fire Door and Other Opening Protective’s in accordance with NFPA 101 18.7.6, 19.7.6, 8.3.3.1, NFPA 80 5.2, 5.2.3. Findings: On 1/7/25, between 10:00 AM and 5:30 PM, this surveyor, observed the following findings with the Facility Coordinator: 1. Painted fire rated door tag located in stairwell on level 1 near MRI room. 2. Painted fire rated door tag located in solid utility on level 1. 3. Painted fire rated door tag located in clean utility on level 1. 4. Painted fire rated door (#1227) tag located in storage room across from kitchen on level 1. 5. Painted fire rated door (#2327) tag located in stairwell near access to employee lounge on level 2. 6. Painted fire rated door, located within stairwell where smoke compartments 2, 3, 4, and 5 intersect. 7. Painted fire rated door, located within corridor outside pharmacy on level 1. 8. Hinge pin located on door entering waiting area for breast health suite on level 2 was not seated, required set pin adjustment. This surveyor confirmed this finding with the Facility Coordinator at time of the observation and review.”

“Gas and Vacuum Piped Systems - Categories CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Categories Medical gas, medical air, surgical vacuum, WAGD, and supply air systems are designated: o Category 1 - Systems in which failure is likely to cause major injury or death. o Category 2 - Systems in which failure is likely to cause minor injury. o Category 3 - Systems in which failure is not likely to cause injury, but can cause discomfort. Deep sedation and general anesthesia are not to be administered using a Category 3 medical gas system. 5.1.1.1, 5.2.1, 5.3.1.1, 5.3.1.5 (NFPA 99) This Standard is not met as evidenced by: 35163 Based on document review and interview, the facility failed to ensure that Medical Gas System was not inspected, tested, and maintained in accordance with NFPA 99, health Care Facilities Code (2012), 5.1.4.8, 5.1.14.1.3, 5.1.14.1.4, 5.1.4.8.8, 5.1.11.2, 5.1.8.3, 5.1.3.3.2(3), 5.1.3.5.6.4, 5.1.10.3, 5.1.3.6.3.12(B), 5.1.10.3.1, 5.1.10.4, 5.1.11.1.3 This deficient practice could affect the facility. patients/residents. visitors, and members of facility staff in the facility. Findings: On 01/07/25 between 10 am-5:30 pm during document review and interview the facility failed to provide documentation that the facility had corrected deficiencies listed on the testing report provided for the 9/16/24 inspection/testing. The following deficiencies were noted: 1. Room 2-medical air outlet is not supplied throught a zone valve 2. Scope room (L119) both vacuum inlets are being used for non medical applications 3. Operating rooms a. Zone valves located left of OR 2 are installed behind a normally open or normally closed door b. Zone valves located right or OR 3 are blocked by a cart c. Sterile room, medical air outlet located in this room is not being used for the application of human respiration and calibration of medical devices for respiratory application. d. The sterile room medical air outlet located in this room is not supplied through a zone valve. 4. Operating room 1 a. 1st Vacuum inlet on the boon has a low flow of 2.25scfm b. 2nd vacuum inlet on boom has a low flow of 2.5 scfm c. WAGD inlet on the boom has a low flow of 2.5 scfm and leaks 5. Operating room 2 a. Nitrogen zone valve located left of OR two leaks at the stem in the on and off positions b. 1st vacuum inlet on the boom has a low flow of 1.5 scfm c. 2nd vacuum inlet on the boom has low flow of 2.25 scfm d. WAGD inlet on the boom has low flow of 2.5 scfm 6. Operating room 3 a. 1st vacuum inlet on boom has low flow of 2.25 scfm b. 2nd vacuum inlet on the boom has low flow of 2.25 scfm c. WAGD inlet on the boom has low low of 2.25 scfm 7. Operating room 40Nitrous oxide outlet on boom 1 drops 9 psig at 3.5 scfm 8. Operating room 5 a. Durin the 10 minute standing pressure teset, the nitrogen system lost 17 psig b. Nitrous Oxide outlet on boom 2 drops 9 psig at 3.5 scfm c. Vacuum outlet on boon 2 has defective latch 9. Imaging Fluoroscopy-1st oxygen outlet leaks with the adapter attached 10. Emergency Department a. Room 1-1st oxygen outlet leaks with the adapter attached b. Room 3-1st vacuum inlet has defective latch c. Room 9-1st vacuum inlet leaks 11. Cardiology/Sleep Lab a. Sleep 1-2nd oxygen outlet leaks with adapter attached b. Sleep Office-1st oxygen outlet leaks with adapter attached 12. Patient Wing a. Oxygen zone valve located left of room 200 leaks at the left flange and the stem in the on and off positions b. Oxygen zone valve located left of room 211 leaks at the left flange and the stem in the on and off positions c. Room 205-1st oxygen outlet leaks with adapter attached d. Room 206-2nd oxygen outlet leaks with adapter attached e. Shower room A (2350)-Oxygen outlet, leaks with adapter attached f. Shower room B (2338) Vacuum inlet has a defective latch g. Room 223-Vacuum has low flow of 2.0 scfm 13. Adult Health a. Room 250 has vacuum inlet leaks and medical air outlet leaks with adapter attached b. Room 254-medical air outlet leaks with adapter attached 14. Cardiology/Sleep a. Zone valves located right of vascular lab need to be relabeled as follows: For oxygen Rooms 2213, 2216, 2217, 2218, 2234, 2237, 2238, 2245, 2246, 2247, and 2248. For vacuum-Rooms 2213, 2216 and 2217. 15. Family Care a. Vacuum zone valve located right of nursery 8 has no vacuum indicator on the station inlet side of the zone value. 16. Room 260-Oxygen outlet leaks with the adapter attached 17. Oxygen Buylt Tank a. Piping as it enters the ground is not protected against possible physicl damage. b. Existing guard posts are not spaced 4 ft between posts on center c. Leaves need to be cleaned up from around the tank as it is combustible material d. Emergency oxygen supply connection-pressure relief vent line needs to be relabeled outside in accordance with 5.1.11.1 to distinguish itself from the medical gas pipeline. 18. In house oxygen components-the gas specific demand check located at the high/low pressure switch is defective and leaks when the pressure switch is removed. 19. Nitrous Oxide Manifold a. Pressure relief vent line needs to be relabeled outside in accordance with 5.1.11.1 to distinguish itself from the medical gas pipeline. b. Pressure relief vent piping on roof is painted c. After the source valve there are multiple threaded connections on the pipelines 20. Nitrogen Manifold-after the source valve there are multiple threaded connections. 21. Carbon Dioxide manifold- Pressure relief vent line needs to be relabeled outside in accordance with 5.1.11.1 to disginguish itself from the medical gas pipeline. 22. Medical Air Compressor-Medical air intake is not located a minimum of 25 feet from ventilating system echausts, fuel storage vents, combustion vents, plumbing vents, vacuum and WAGD discharges, or areas that can collect vehicular exhausts or other noxious fumers. 23. Vacuum/WAGD Pump a. A section of the main piping is soft soldered and not made with acceptable joining methods b. Exhaust piping on the roof is painted These findings were verified by the facility executive director and facilities coordinator at the time of document review on 01-07-25. Based on observation, the health care facility failed to ensure that Gas Equipment - Medical Gas zone valves shall be readiliy accessible outside each vital life-support area, critical care area, and anesthetizing areas in accordance with NFPA 101, LIfe Safety Code 2012 edition section 19.3.2.4 and NFPA 99, Health Care Facilities Code, 2012 edition 5.1.4.8.7 (5.1.4.8.4). This deficient practice could affect the patients/residents, visitors, and members of facility staff in location(s). Deficient practices have the potential of allowing an emergent condition to enhance due to the lack of accessibility to the control isolation valves. Findings: On 1/7/2025, between 10:00 AM and 5:50 PM a surveyor, with the Carpenter present, observed the following: 1. The Medical Gas zone valve control located between the utility storage and clean utility room in the ICU suite was blocked from access by stored items. The surveyor confirmed this finding with the Carpenter at the time of the observation.”

“Gas and Vacuum Piped Systems - Warning System CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Warning Systems All master, area, and local alarm systems used for medical gas and vacuum systems comply with appropriate Category warning system requirements, as applicable. 5.1.9, 5.2.9, 5.3.6.2.2 (NFPA 99) This Standard is not met as evidenced by: 35163 Based on document review and interview, the facility failed to ensure that Medical Gas System was not inspected, tested, and maintained in accordance with NFPA 99, Health Care Facilities Code (2012), 5.1.9.3, 5.1.9.2.1 (1), 5.1.8.2.2 (2), 5.1.9.1 (1). This deficient practice could affect the facility, patients/residents, visitors, and members of facility staff in the facility. Findings: On 01/07/25 between 10 am- 5:30 pm during document review and interview the facility failed to provide documentation that the facility had corrected deficiencies listed on the testing report provided for the 9/16/24 inspection/testing. The following deficiencies were noted: 1. Area alarm located at back office, left of room one, has no accurate pressure displays. 2. Master alarm panel locted at the back switchboard is not installed at a location in the office or workspace of the on-site individual responsible for the maintenance of the medical gas and vacuum piping system. 3. Special Procedure - Area alarm panel located in back office left of room 1 a. Has no pressure/vacuum indicator at the alarm panel for each system that is monitored. b. Medical air is not monitored for this department 4. Imaging a. Area alarm panel located right of reading room in the back area is non-compliant Black ohio panel which does not distinguish between increase or decrease of 20 percent from the normal line pressure and has recall for a potential fire hazard. 5. ICU Area alarmpanel located at the nurses station. a. Vacuum needs the alarm sensor installed on the patient or use side of the zone valve box assembly b. Is a non-complaint Black ohio panel which does not distinguish between increase or decrease of 20 percent from the normal line pressure and has recall for a ptential fire hazard.”

“Electrical Systems - Wet Procedure Locations CFR(s): NFPA 101 Electrical Systems - Wet Procedure Locations Operating rooms are considered wet procedure locations, unless otherwise determined by a risk assessment conducted by the facility governing body. Operating rooms defined as wet locations are protected by either isolated power or ground-fault circuit interrupters. A written record of the risk assessment is maintained and available for inspection. 6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2 This Standard is not met as evidenced by: 35163 Based on document review and interview the facility failed to provide documentation to ensure that the operating rooms were protected by either isolated power or ground-fault circuit interrupters or that a risk assessment was completed for these locations per NFPA 99, Health Care Facilities Code (2012). 6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2. This deficient practice could affect the facility, patients/residents, visitors, and members of facility staff in the facility. Findings; 1. It could not be determined if the facilities operating rooms which are considered wet locations had appropriate protection or that risk assessment had appropriate protection or that risk assessment had been completed. No documentation wa provided upon request at time of inspection. These findings were verified by the facility executive director and facilities coordinator at the time of document review 01-07-25.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 16732 The Healthcare facility failed to test hospital grade receptacles and Line isolation monitors in accordance with NFPA 99 Section 6.3.4 and records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) Finding: Based on observation and interview on 01-07-2025 between the hours of 10:00 AM and 5:30 PM, a surveyor observed the following: 1. Record review shows no documentation that hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of. 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals < 12 months. There are no records maintained of required test and associated repairs,or modification, containing date, room or area tested, and results. An interview with facillity electrician confirmed this finding.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 16732 The hospital failed to maintain and test the Essential Electrical System in accordance with NFPA99, NFPA 110. Findings: Based on record review and interview on 01-07-2025 between hours of 10:00 AM and 5:30 PM, a surveyor observed the following: 1. There is no documentation for maintenance and testing of the generator transfer switches are performed in accordance with NFPA 110 for the facilities four generators. 2. There is no documentation generator sets(four generators) are exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. The facility electrician confirmed these findings”

“Electrical Equipment - Other CFR(s): NFPA 101 Electrical Equipment - Other List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 10 (NFPA 99) This Standard is not met as evidenced by: 47175 Based on observation, the health care facility failed to ensure that electrical equipment components are mainteained and protected in accordance with the requirements described in NFPA 70 (2011) National Electrical Code and that all pull boxes, junction boxes, and fittings shall be provided with covers. If metal covers are used, they shall be grounded. In energized installations each outlet box shall have a cover, faceplate, or fixture canopy. Finding: On 1/7/2025, between 10:00 AM and 5:30 PM, a surveyor, with the Carpenter present, obsreved the following: 1. An electrical junciton box was found in the purchasing office in the receiving area missing the faceplate cover leaving the interior wiring exposed. The surveyor confirmed this finding with the Carpenter at the time of the observation. 50053 Based on observation, the health care facility failed to ensure that electrical equipment components are maintained and protected in accordance with the requirements described in NFPA 70 (2011) National Electrical Code and that all pull boxes, junction boxes, and fittings shall be provided with covers. If metal covers are used, they shall be grounded. In energized installations each outlet box shall have a cover, faceplate, or fixture canopy. Finding: On 1/7/2025, between 10:00 AM and 5:30 PM, a surveyor, with the Carpenter present, observed the following: 1. An electrical junction box was found in the stairwell on level 2 where smoke compartments 2, 3, 4, 5 intersect missing the faceplate cover leaving the interior wiring exposed. 2. 1. An electrical junction box was found on level 2 of stairwell in some compartment #1 missing the faceplate cover leaving the interior wiring exposed. The surveyor confirmed this finding with the Facility Coordinator at the time of the observation.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 47175 Based on observation and interview, the long-term care facility failed to ensure that power strips are not used for non-PCREE (Patient-care-related electrical equipment) and that power strips are not used as a substitute for fixed wiring in accordance with NFPA 99 Chapter 10, NFPA 70 chapter 4 {400.8(1)} On 01/07/2024, between 10:30 AM and 5:30 PM, surveyor, with the Carpenter present observed the following: 1. A mini-fridge was found plugged into a portable power tap which was daisy chained to another portable power tap under a desk located at the X-Ray reading room office behind door 1- 082 The surveyor confirmed this finding with the Carpenter at the time of the observation. Based on observation and interview, the long-term care facility failed to ensure that power strips are not used for non-PCREE (Patient-care-related electrical equipment) and that power strips are not used as a substitute for fixed wiring in accordance with NFPA 99 Chapter 10, NFPA 70 chapter4 {400.8(1)} On 01/07/2024, between 10:30 AM and 5:30 PM, surveyor, with the Carpenter present observed the following: 1. Portable heaters were found plugged into power strips rather than fixed wiring in the following areas: a. In X-ray waiting room underneath the receptionist desk. Underneath a technicians desk in the laboratory. The surveyor confirmed this finding with the Carpenter at the time of the observation.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 35163 Based on document revie and interview, the facility failed to ensure that Gas and Cylinder Storage was maintained in accordance with NFPA 99, Health Care Facilities Code (2012). 11.6.2.3 (11), 11.3.2.3, 11.6.5.2 This deficient practice could affect the faciliy, patients/residents, visitors, and members of facility staff in the facility. Findings: 1. The medical gas tank storage room (near hazardous waste room) had oxygen cylinders that were free standing and not secured. 2. Themedical gas tank storage room (near hazardous waste room) had combustible itesmwithin locatedin the room and within 5’ of the stored oxygen cylinders (wooden studs on walls and cardboard boxes with combustible materials not associated with oxygen delivery equipment 3. The medical gas tank storage room (near haxardous waste room) had dylinders that were not properly labeled/separated from full and empty cylinders. On 01/07/25 between 10 am-5:30 pm during document review and interview the facility failed to provide documentation that the facility had corrected deficiencies listed on the testing report provided for the 9/16/24 inspection/testing. The following deficiencies were noted. 47175 Based on observartion, the health care facility failed to ensure that Gas Equipment - Cylinder and Container Storage in a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.3 in NFPA 99 (2012). A precautionary sign readable from 5 feet is on each door or gate of cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING,” Finding: On 1/07/2025 between 10:00 AM and 5:30 PM, a surveyor, with the Carpenter observed the following;: 1. The clean utility room in the ICU was found being used for oxygen tank storage less than 300 cubic feet and was not marked with a sign readable from 5 ft stating “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING” The surveyor confirmed this finding with the Carpenter at the time of the observation.”

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 49750 Based on document reviews, observations and interviews, the hospital failed to ensure that policies and procedures were established to assure safe and clean storage of supplies for direct patient care with the Medical Supplies Department and the Infection Control Department, for all individuals seeking care in the Emergency Department. Findings: On 9/18/2024 at 10:58 AM, the Inventory Control policy and procedure for the Emergency Department (“ED”) was requested. On 9/18/2024 at 3:16 PM, an email was received from the Director of Quality and Risk. He was unable to provide any such policy. On 09/18/2024 at 8:50 AM, a tour of the emergency department was conducted with the Director of Emergency Services and Director of Quality and Risk Management. This tour revealed the following: : Triage Room findings: -Adhesive tape residue present on glucometer meter and glucometer kit creating a non-intact surface. Not easily sanitized -Chair in triage has non-intact surface. -These non-intact surfaces that could not be sanitized. EKG machine outside Triage Room: -Adhesive tape residue on monitory creating a non-intact surface. These non-intact surfaces that could not be sanitized. -Supply tray had debris in bottom of tray, - Crash Cart outside Triage Room: -Defibrillator Monitor soiled. ED Rm. 2: -Computer monitor has multiple areas of adhesive tape residue on screen frame and screen. -Computer cart wrist rest has large area missing creating a nonintact surface. -Computer keyboard has copious amounts of debris below/between keys. Not sanitary. -Portable cardiac monitor on wall arm has multiple areas of adhesive tape debris creating a non-intact surface. -Wooden headboard has multiple non-intact surfaced on bottom edge of headboard creating a non-intact surface. -Shelving above counter to right side of bed which contained patient supplies had adhesive tape residue on the edge of both shelves creating a non-intact surface. -These non-intact surfaces that could not be sanitized. -Needle, empty syringe, and pre-filled flush noted on counter to right of bed. Not secured. -2 of 2 BD BBL NS expired. One syringe expired 07/2023 and the other expired 06/2024. -1 of 1 Hologic Swab Specimen Collector expired 04/30/2024 -1 of 2 nasal swab specimen collection item was unwrapped and amongst the sterile supplies. -1 of 2 Culture Swab kits expired 09/30/2023. -1 of 4 Triple Pack Povidine Iodine packages contaminated and amongst the sterile supplies. -2 of 2 clear-top blood collection tubes expired 05/31/2024 Patient nutrition station with hand hygiene sink located next to staff working station: -Opened bottle of ginger ale and Pepsi sitting out on counter. -Otoscope/Ophthalmoscope handles present in battery pack plugged into electrical outlet charging. -Bin located to the right of the ophthalmoscope contained: -2 of 2 opened packages of otoscope caps/cones -1 of 1 black marker -5 of 5 soiled ophthalmoscope heads -2 of 2 soiled otoscope heads -1 of 1 Panoptix ophthalmic instrument which is soiled. -1-Bottom of bin which contained the ophthalmoscope/otoscope heads had a layer of debris and was not sanitary. Ambulance Entrance/Port: -Water damage noted to ceiling at ambulance entrance. ED Rm. 7/Critical Care Room: -Pediatric Crash cart tip drawer has adhesive tape debris creating a non-intact surface. -Adhesive tape debris stuck to floor in front of the Pedi Crash Cart creating a non-intact surface. -These non-intact surfaces that could not be sanitized. -Needle Decompression Box: -2 of 2 20-cc Syringes both expired 11/30/2023 -2 of 2 3-way Hi-Flow Stopcocks expired on 7/22/2022 -4 of 4 14G x 2-inch needles expired on 09/30/2023 -ED Rm 7 Computer stand: -Work surface on stand contains debris. -Computer keyboard has missing keys and debris under keys. -Computer monitor has multiple areas of adhesive tape debris creating a non-intact surface. -These non-intact surfaces that could not be sanitized. -ED Rm 7 Adult Crash cart: -Top of cart has debris and not sanitary. -ED Rm 7 Intubation Box: -2 of 2 Arterial line sets expired 09/1/2024 -7 of 7 Nellcor Pediatric Calorimetric CO2 detectors expired 9/12/2024 -ED Rm 7 Glucometer Kit on countertop: -One section of the interior of box has debris in the bottom. -Outside of box is soiled and had adhesive tape residue creating a non-intact surface. -These non-intact surfaces that could not be sanitized. -ED Rm. 7-Electric Razor handle: -Razor head receiver is soiled and pieces of hair is present. Suture Cart: -1 of 2 multiuse bottles of Bupivicaine vials and not labeled appropriately. -1 of 1 multiuse bottles of Lidocaine 1% vials opened and not labeled appropriately. -1 of 1 multiuse bottles of Xylocaine 1% vials opened and not labeled appropriately. -1 of 1 multiuse bottles of Lidocaine 2% vials opened and not labeled appropriately. -1 of 45 5-0 Prolene suture packs expired 07/31/2024 -7 of 12 6-0 Prolene suture packs expired 9/30/2023 -6 of 27 5-0 Vicryl suture packs expired 9/30/2023 -1 of 15 4-0 Vicryl suture packs expired 11/30/2023 -1 of 20 5-0 Vicryl suture packs expired 01/31/2024 Ear, Nose, and Throat Cart: -1 of 1 Box of red tube-like adapters to apply to Xylocaine spray for application was soiled and contaminated. -1 of 1 Box of Katz extractors soiled and contaminated. -1 of 1 Sterile McGill Forceps expired 07/31/2023 Area where registration/tech/pharmacy tech stations located: -Damaged/broken ceiling tiles. Medication Room: -Counter where medication is prepared is soiled with multiple areas of white dried matter. All above findings were confirmed by the Director of Emergency Services and Director of Quality and Risk Management at the time of discovery.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 49750 Based on document reviews and interviews, the hospital failed to ensure that Emergency Department policies were reviewed and updated for thirteen (13) of seventeen (17) policies reviewed. Findings: This is a repeat deficiency from the previous survey completed in July 2024. The Director of Quality and Risk and the Corporate Compliance Officer stated they use a software that prompts the facility to review policies and procedures every three (3) years. On 09/18/2024 and 9/19/2024, Emergency Department (“ED”) policies were reviewed with the Director of Quality and Risk. The following policies have not met the hospital expectation for policy review: - Violence: Physical Assault, last approved on 09/2018, next to be reviewed by 08/2021; - Safe Haven for Abandoned Infants Dropped Off at Hospital, last approved on 02/2012, next to be reviewed by 01/2015; - Capacity Management Plan Code Purple (Surge Capacity), last approved on 06/2011, next to be reviewed by 05/2014; - Controlled Medications and Pyxis Access, last approved on 10/2018, next to be reviewed by 09/2021; - Domestic Violence, last approved on 12/2019, next to be reviewed by 12/2022; - Emergent Care & Wells ERgent Care Procedural & Deep Sedation Policy, last approved 12//2019, next t be reviewed by 12/2022; - Legal Claim of Evidence, last approved on 01/2020, next to be reviewed by 01/2023; - Restrictions of Procedures Performed, last approved on 10/2019, next to be reviewed by 10/2022; - Review of Lab/Radiology Reports last approved on 01/2020, next to be reviewed by 01/2023; - Triage Guidelines, last approved on 11/2018, next to be reviewed by 10/2021; - Blood Alcohol Samples : Consent and Drawing, last approved on 07/2019, next to be reviewed by 06/2022; - Dispensing of Medication: Emergency Department, last approved on 09/2021, next to be reviewed by 08/2024; and - Care of the Patient with Suicidal/Homicidal Ideation, last approved on 05/2018, next to be reviewed by 04/2021. The above findings were confirmed at the time of the review with the Director of Quality and Risk.”

“ELIGIBILITY & PROCESS FOR APPT TO MED STAFF CFR(s): 482.22(a) The medical staff must be composed of doctors of medicine or osteopathy. In accordance with State law, including scope of practice laws, the medical staff may also include other categories of physicians (as listed at §482.12(c)(1)) and non-physician practitioners who are determined to be eligible for appointment by the governing body. This Standard is not met as evidenced by: 49750 Repeat Deficiency Based on document reviews and interviews, the hospital failed to ensure that all Providers who provided care to patients were evaluated consistent with the “York Hospital Medical Staff, Bylaws, Rules & Regulations” for seven (7) of eight (8) Providers (Provider #2 - #8). Findings: During a previous complaint survey, which was completed on 3/27/19, it was determined that a Vascular Surgeon, who was on call for the hospital, had performed surgery on a patient and was not licensed in the State of Maine to practice and the hospital’s Medical Staff Bylaws had not been followed. As a result, the hospital was cited for its failure to ensure all providers, who provided care to patients, were evaluated consistent with the “York Hospital, Medical Staff, Bylaws, Rules & Regulations” for 1 of 1 physician. The hospital’s plan of correction (POC), dated 4/19/19, indicated the following: the Medical Staff would be educated on the need for Maine licensure even in emergent situations; the Medical Bylaws would be revised to clarify that in all cases, including emergency situations, the providers at York Hospital must be legally authorized (licensed) to practice within the State of Maine; all credentialed providers would attest that they understood Maine licensure requirements and process for emergency privileges; and the updated bylaws would be distributed to each remember of the Medical Staff, with a memo noting the specific requirement of Maine licensure. The POC indicated that the hospital would be in compliance with this regulation by 5/10/19. The “York Hospital Medical Staff Bylaws, Rules & Regulations” were reviewed and states in part ... following: “Article II: Medical Staff Membership -Section 1. Medical Staff Appointment stated, Appointment to the Medical Staff of York Hospital is a privilege which shall be extended only to competent professional who continuously meet the qualifications, standards, and requirements set forth in these Bylaws, Rules & Regulations, and associated policies of the medical Staff and Hospital...In addition, all Medical Staff - are required to comply with all applicable State and Federal Regulations, and Policies of the Medical Staff and any other applicable departmental or divisional rules, regulations and policies.” - Section 2: Qualifications for Membership A. Only providers with Doctor of Medicine or Doctor of Osteopathy Degrees, Dentists, Oral Surgeons, Podiatrists, or RNFA’s, NP’s, PA’s, CNM’s, FNP’s, ANP’s and APRN’s, holding a license to practice in the State of Maine, who can document their current licensure, background, experience, relevant training and or licensure, judgement, individual charter, and demonstrated current competence, physical and mental capabilities and health status, adherence to the ethics of their profession, and ability to work with others with sufficient adequacy to ensure the Medical Staff and the Board of Trustees that any patient treated by them in Hospital will be given a high degree of patient care, shall be considered for appointment to the Medical Staff.” On 7/11/2024, eight (8) Provider (“PV”) credentialing files were reviewed with Administrator (ADM) #1. This review revealed the following: - PV #2, PV #3, PV #5, PV #7, and PV #8 credentialing file fail to include a signed Requested Privileges form by Department Chief, Bylaws & Credentials Committee, Medical Executive Committee or Board of Trustees. - PV #4 and PV #6 credentialing files did not have evidence of a National Provider Bank verification form. - PV #3 credentialing failed to contain an Advanced Practice Registered Nurse independent practice license. The above findings were confirmed with ADM #1 at the time of review. On 7/11/2024 at 1:25 PM, PV #3 confirmed during a telephone interview that she failed to petition the Maine State Board of Nursing for independent practice. She also confirmed that she did not currently have a supervising physician.”

“MEDICAL STAFF RESPONSIBILITIES - H&P CFR(s): 482.22(c)(5)(i) [ The bylaws must:] Include a requirement that-- (i) A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(5)(iii) of this section. The medical history and physical examination must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oral and maxillofacial surgeon, or other qualified individual in accordance with State law and hospital policy. This Standard is not met as evidenced by: 49750 Based on document reviews and interviews, the hospital failed to ensure that Providers accurately completed the history and physical documentation for six (6) of ten (10) patients reviewed (Patient #6, #10, #11, #12, #14 and #15). Findings: The “York Hospital Medical Staff Bylaws, Rules & Regulations”, last reviewed on 05/2019 states, in part, following ...: “History and Physical (H&P) requirements for admissions: a. A complete H&P must be done within 30 days of admission b. A new H&P is required for any H&P older than 30 days c. It must be placed on the medical record and updated within 24 hours of admission. The history and physical may be hand-written in the progress note but must be labeled as such. If dictated, it must be completed within 16 hours of admission to allow for transcription of the dictated report. d. A complete history and physical contains documentation of: -Chief complaint -Present illness -Family history -Psychological status/social history -Past medical history, allergies and medications -Review of systems” And ... “Brief History and Physical for uncomplicated ambulatory outpatients: a. A short form may be used for uncomplicated ambulatory patients. b. It must be completed no more than 30 days prior to outpatient surgery and updated withing 24 hours, but prior to surgery c. The H&P must be on the medical records prior to an invasive procedure. d. A brief history contains documentation of : -Chief complaint -Present illness -Family history -Psychological status/social history -Past medical history e. A brief physical exam contains documentation of findings regarding a focused physical exam. f. In addition, a history and physical contains documentation of conclusions/impressions and plan of care ... .” On 7/09/2024 at 3:00 PM, ten (10) patient medical records were reviewed with Administrator (“ADM”) #2 and revealed the following: -Patient #6’s history and physical failed to document a review of systems; -Patient #10’s history and physical failed to document conclusions/impressions and plan of care; -Patient #11’s history and physical failed to document a chief complaint; -Patient #12’s history and physical failed to document a family history; -Patient #14’s history and physical failed to document a family history and current medications; and -Patient #15’s history and physical failed to document a chief complaint. The above findings were confirmed with ADM #2 at the time of the review.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 50294 Based on document reviews and interviews, the hospital failed to ensure that Emergency Department policies were reviewed and updated for seventeen (17) of twenty-one (21) policies reviewed. Findings: On 07/09/2024 at 4:10 PM, a request was made for the policy regarding the frequency and management of hospital policies. The Director of Quality and Director of Corporate Compliance and Privacy stated they use a software that prompts the facility to review policies and procedures. On 7/09/2024 and 7/10/2024, Emergency Department (“ED”) policies were reviewed with the Director of Quality and Director of Corporate Compliance and Privacy. The following policies have not met the hospital expectation for policy review: - Safe Haven for Abandoned Infants Dropped Off at Hospital, last approved on 02/2012, next to be reviewed by 01/2015; - Violence: Physical Assault, last approved on 09/2018, next to be reviewed by 08/2021; - Restrictions of Procedures Performed, last approved on 10/2019, next to be reviewed by 10/2022; - Management of Critically Ill Children, last approved on 11/2011, next to be reviewed by 10/2014; - Triage Guidelines, last approved on 11/2018, next to be reviewed by 10/2021; - Suture Removal, last approved on 12/2019, next to be reviewed by 10/2022; - Review of Lab/Radiology Reports last approved on 01/2020, next to be reviewed by 01/2023; - Legal Claim of Evidence, last approved on 01/2020, next to be reviewed by 01/2023; - Guidelines for Transfer from Wells Emergency or Walk-In Care, last approved on 12/2018, next to be reviewed by 11/2021; - Procedural & Deep Sedation, last approved on 12/2019, next to be reviewed by 12/2022; - Emergency Patients in Radiology, last approved on 10/2019, next to be reviewed by 10/2022; - Care of the Patient with Suicidal/Homicidal Ideation, last approved on 05/2018, next to be reviewed by 04/2021; - Domestic Violence, last approved on 12/2019, next to be reviewed by 12/2022; - Controlled Medications and Pyxis Access, last approved on 10/2018, next to be reviewed by 09/2021; - Blood Alcohol Samples : Consent and Drawing, last approved on 07/2019, next to be reviewed by 06/2022; - Helicopter Transfer, last approved on 01/2020, next to be reviewed by 01/2023; and - Capacity Management Plan Code Purple (Surge Capacity), last approved on 06/2011, next to be reviewed by 05/2014. The above findings were confirmed at the time of the review with the Director of Quality and Director of Corporate Compliance and Privacy. The Director of Quality and Director of Corporate Compliance and Privacy stated that they are “Not organizationally ready. We have a program/software for policies. Our committee will be resurrected when culturally appropriate.””